Please email motherhealth@gmail.com for any suggestions related to cancer care coordination and measurement.

The rapid adoption of Electronic Health Records (EHRs), increased patient engagement, rapid adoption of mobile technology, and shift to value-based care have contributed to an increased use of health information technology (IT) to improve quality and outcomes of patient care.

There is a need for more coordination in cancer care due to the growing complexity of cancer treatment and the increase in cancer survivors that need better coordination within and across clinical teams and care settings. Poorly coordinated care leads to avoidable hospital readmissions, preventable medical errors, harm to patients and higher costs. Care coordination strategies share seven essential tasks: assess patient, develop care plan, identify participants and specify roles, communicate with patients and other participants, execute care plan, monitor and adjust care, and evaluate outcomes. Health IT plays an important role in care coordination in diverse organizations like Kaiser Permanente and the VA.

The measurement process for care coordination is changing from the laborious process of manual chart reviews to EHR-based measurement.

Care Coordination is a multi-dimensional concept that encompasses many facets of healthcare organization and delivery. Because poorly coordinated care regularly leads to unnecessary suffering for patients, as well as avoidable readmissions and emergency department visits, increased medical errors, and higher costs, coordination of care is increasingly recognized as critical for improvement of patient outcomes and the success of healthcare systems. In Phase 3 of this project, measures submitted focused on key areas of emergency department transfers, medication reconciliation and timely transitions. This report focuses on the evaluation of one newly submitted and four care coordination measures undergoing maintenance review for suitability as voluntary consensus standards.

Example of what will be monitored: medication and medication reconciliation

Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient

Description: This measure assesses the actual quality of the medication reconciliation process by identifying errors in admission and discharge medication orders due to problems with the medication reconciliation process. The target population is any hospitalized adul

Numerator Statement: For each sampled inpatient in the denominator, the total number of unintentional medication discrepancies in admission orders plus the total number of unintentional medication discrepancies in discharge orders.

Denominator Statement: The patient denominator includes a random sample of all potential adults admitted to the hospital. Our recommendation is that 25 patients are sampled per month, or approximately 1 patient per weekday.

So, for example, if among those 25 patients, 75 unin

Exclusions: Patients that are discharged or expire before a gold standard medication list can be obtained.

Adjustment/Stratification:

Level of Analysis: Facility

Setting of Care: Hospital/Acute Care Facility

Type of Measure: Outcome