With the emergence of electronic health records (EHRs) and administrative and professional databases, it’s critical to facilitate clear communication and assure the accurate interchange of data and information. Clinical data standards are important for managing patients, assessing outcomes, and conducting research. Having a broad agreement on a common vocabulary and a standardized list of data elements helps lay the groundwork for future clinical registries and quality- improvement initiatives. It also can be used in the development of performance measures.
An Important Update
In 2013, the American College of Cardiology (ACC) and American Heart Association (AHA), in conjunction with 11 other organizations, developed a list of key data elements with standardized definitions for patients with acute coronary syndromes (ACS) and coronary artery disease (CAD). The document was published jointly in the Journal of the American College of Cardiology and Circulation. It updates information on elements specific to ACS that were released in 2001. CAD was added because of the overlap between the two conditions.
The ACC/AHA publication listed key data elements and provided detailed definitions in seven categories, including demographics and admissions; history and risk factors; clinical presentation; diagnostic procedure; invasive therapeutic intervention; medications; and outcomes. The document is organized in tabular form to be a helpful tool for everyday use. Special attention is also given to important predictors of outcomes, including laboratory results and clinical presentation.
This information should be mandatory reading for clinical investigators, quality assurance personnel, and research nurses. For cardiologists, the latest terminology and methods may seem obvious at first glance. However, even the most sophisticated practitioners can discover better ways to communicate and describe ambiguous situations and improve their clinical approach. The document aims to ensure that everyone is on the same page.
Looking Ahead for ACS and CAD
Incorporating key data elements and standardized definitions for ACS and CAD into EHRs and clinical management tools will be challenging; it’s difficult to collect data seamlessly during clinical care. However, this information represents a necessary step in developing a universal system that streamlines the medical records process by creating a common structure. There is no small task in our increasingly complex and electronic healthcare arena. It’s hoped that this information proves useful within the everyday clinical environment and is used to set the tone for what data are collected, which outcomes are assessed, and how quality is ultimately measured in ACS and CAD.
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