Table 2

Care by Design Implementation Data Elements and Sources

Data Element or OutcomeSourceLevel at Which CollectedLevel at Which ReportedSampleTime Period
Data Element
Appropriate access
 Same-day appointmentsReportAppointmentClinicianAll patient appointments scheduledQuarter
 Seen by primary care clinician at last visitChart auditPatientClinicianPatient sample AMonth
 Response to messages (first contact)ReportTeamMessage pool teamAll patientsWeek
 Call abandonment rate (call center)ReportQueue level averaged to get center numberCenterAll patientsMonth
 Calls answered within standard (call center)ReportQueue level averaged to get center numberCenterAll patientsMonth
 Percent of patients signed up for MyChartaReportPatient assigned to primary care clinician everClinicianAll patients assigned to primary care clinicianEver
Care team
 Use of X-filesb by MAChart auditPatientClinicianPatient sample AMonth
 Clinician uses physical templateChart auditPatientClinicianPatient sample AMonth
 Response to BPAsChart auditPatientClinicianPatient sample AMonth
 Standardized stocking of examination rooms /planObservationExamination roomClinicianN/ADay of observation
 Huddles and schedule reviewsInterviewClinicianClinicianN/ADay of observation
 Efficient visit (<10-min wait throughout visit)ObservationPatientClinicianAll visits observedDay of observation
 Blood draws done in roomObservation or interviewClinicianClinicianAll visits observedDay of observation
 Continuity of MA throughout patient visitObservationPatientClinicianAll visits observedDay of observation
 MA engagement in visit (use of X-files, BPAs, scribe, orders, AVS, referrals, follow-up appointment)Observation or InterviewClinicianClinicianAll visits observedDay of observation
 Documentation of patient communication needsChart auditPatientClinicianPatient sample AMonth
 Presence of advance directivesChart auditPatientClinicianPatient sample AMonth
 PHQ-2 or -9Chart auditPatientClinicianPatient sample AMonth
 List of community resources for common needsObservationCenterClinicianN/ADay of observation
 Efficient communication among team membersObservationTeamClinicianN/ADay of observation
Planned care
 Use of registriesObservation or interviewClinicianClinicianN/ADay of observation
 Labs done prior to visitChart auditPatientClinicianPatient sample CMonth
 AVS given to patientReportPatientClinicianAll patients seenMonth
 Medication reconciliation at last visitChart auditPatientClinicianPatient sample AMonth
 Procedure/consult notes available at follow-up visitChart auditPatientClinicianPatient sample BMonth
 Care plan documented for high-risk/important conditionsChart auditPatientClinicianPatient sample CMonth
 Track progress on care plan and action stepsChart auditPatientClinicianPatient sample CMonth
 Contact patient postdischargeChart auditPatientClinicianPatient sample DMonth
Clinician satisfactionReport (AMGA)ClinicianCenterN/AAnnual
Patient satisfactionReport (Press Ganey)PatientClinicianAll patients with e-mailQuarter
Quality dataReportPatientClinicianVariedAggregate of 12 or 13 months ending June 2011
  • AMGA = American Medical Group Association; AVS = After-Visit Summary; BPA = Best Practice Alert; CBD = Care by Design; EHR =electronic health record; MA = medical assistant; PHQ = Patient Health Questionnaire; N/A = not applicable.

  • a Patient portal in the EHR.

  • b Patient history template in the EHR.