Prioritization and Refinement of Clinical Data Elements within EHR Systems

摘要

Standardization of clinical data element (CDE) definitions is foundational to track, interpret, and analyze patient states, populations, and costs across providers, settings and time – critical activities to achieve the Triple Aim: improving the experience of care, improving the health of populations, and reducing per capita healthcare costs. We defined and implemented two analytical methods to prioritize and refine CDE definitions within electronic health records (EHRs), taking into account resource restrictions to carry out the analysis and configuration changes: 1) analysis of downstream data needs to identify high priority clinical topics, and 2) gap analysis of EHR CDEs when compared to reference models for the same clinical topics. We present use cases for six clinical topics. Pain Assessment and Skin Alteration Assessment were topics with the highest regulatory and non-regulatory downstream data needs and with significant gaps across documention artifacts in our system, confirming that these topics should be refined first.