Table 2

Care by Design Implementation Data Elements and Sources

Data Element or Outcome	Source	Level at Which Collected	Level at Which Reported	Sample	Time Period
Data Element
Appropriate access
Same-day appointments	Report	Appointment	Clinician	All patient appointments scheduled	Quarter
Seen by primary care clinician at last visit	Chart audit	Patient	Clinician	Patient sample A	Month
Response to messages (first contact)	Report	Team	Message pool team	All patients	Week
Call abandonment rate (call center)	Report	Queue level averaged to get center number	Center	All patients	Month
Calls answered within standard (call center)	Report	Queue level averaged to get center number	Center	All patients	Month
Percent of patients signed up for MyChart^a	Report	Patient assigned to primary care clinician ever	Clinician	All patients assigned to primary care clinician	Ever
Care team
Use of X-files^b by MA	Chart audit	Patient	Clinician	Patient sample A	Month
Clinician uses physical template	Chart audit	Patient	Clinician	Patient sample A	Month
Response to BPAs	Chart audit	Patient	Clinician	Patient sample A	Month
Standardized stocking of examination rooms /plan	Observation	Examination room	Clinician	N/A	Day of observation
Huddles and schedule reviews	Interview	Clinician	Clinician	N/A	Day of observation
Efficient visit (<10-min wait throughout visit)	Observation	Patient	Clinician	All visits observed	Day of observation
Blood draws done in room	Observation or interview	Clinician	Clinician	All visits observed	Day of observation
Continuity of MA throughout patient visit	Observation	Patient	Clinician	All visits observed	Day of observation
MA engagement in visit (use of X-files, BPAs, scribe, orders, AVS, referrals, follow-up appointment)	Observation or Interview	Clinician	Clinician	All visits observed	Day of observation
Documentation of patient communication needs	Chart audit	Patient	Clinician	Patient sample A	Month
Presence of advance directives	Chart audit	Patient	Clinician	Patient sample A	Month
PHQ-2 or -9	Chart audit	Patient	Clinician	Patient sample A	Month
List of community resources for common needs	Observation	Center	Clinician	N/A	Day of observation
Efficient communication among team members	Observation	Team	Clinician	N/A	Day of observation
Planned care
Use of registries	Observation or interview	Clinician	Clinician	N/A	Day of observation
Labs done prior to visit	Chart audit	Patient	Clinician	Patient sample C	Month
AVS given to patient	Report	Patient	Clinician	All patients seen	Month
Medication reconciliation at last visit	Chart audit	Patient	Clinician	Patient sample A	Month
Procedure/consult notes available at follow-up visit	Chart audit	Patient	Clinician	Patient sample B	Month
Care plan documented for high-risk/important conditions	Chart audit	Patient	Clinician	Patient sample C	Month
Track progress on care plan and action steps	Chart audit	Patient	Clinician	Patient sample C	Month
Contact patient postdischarge	Chart audit	Patient	Clinician	Patient sample D	Month
Outcome
Clinician satisfaction	Report (AMGA)	Clinician	Center	N/A	Annual
Patient satisfaction	Report (Press Ganey)	Patient	Clinician	All patients with e-mail	Quarter
Quality data	Report	Patient	Clinician	Varied	Aggregate of 12 or 13 months ending June 2011
Productivity	Report	Clinician	Clinician	N/A	Annual
Financials	Report	Center	Center	N/A	Annual

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.