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Clinical Content Enhancement Toolkit


About the Grants

AHRQ initiated a research program that awarded eight grants in September 2010 to improve statewide all-payer, hospital-based encounter-level data (inpatient, emergency department, and ambulatory surgery) for the purpose of both producing the evidence base for comparative effectiveness and evaluating efforts to implement comparative effectiveness where the evidence already exists. Two types of grants were implemented under this research program to improve state data by:
  • Enhancing the clinical content of the state databases in Florida, Hawaii, Minnesota, New Jersey, and New York
  • Improving the race/ethnicity data in state databases in California, New Mexico, and the Northwest region (Idaho, Oregon, and Washington)
The grant projects were conducted over a 3-year period. Information about lessons learned and tools for other state data organizations to adopt the improvements are being disseminated via this toolkit as well as a companion toolkit on enhancing race/ethnicity data.

Florida Grantee

GRANT SUMMARY: Investigators at the University of South Florida leveraged a strong collaborative partnership among many of Florida's key healthcare entities to create a statewide enhanced maternal–infant database of clinical and nonclinical information derived from birth and death vital records, as well as inpatient, ambulatory, and emergency department data. The end product was tested by conducting a comparative effectiveness research study using early-term elective delivery as a case study. The database serves as a sustainable tool for research, quality improvement, and enhancement of overall health, and as a model for other states with similar objectives.

Florida Contacts

University of South Florida (USF) Department of Epidemiology and Biostatistics, College of Public Health
Principal Investigator: Hamisu M. Salihu, MD, PhD
Alfred Mbah, PhD
Jason L. Salemi, MPH
Abraham Salinas, MD, PhD

USF Department of Obstetrics and Gynecology, College of Medicine
Investigator: Valerie Whiteman, MD

USF Department of Community and Family Health, College of Public Health
Collaborator: William Sappenfield, MD, MPH

USF Division of Evidence-Based Medicine and Outcomes Research, Clinical and Translational Sciences Institute
Benjamin Djulbegovic, MD, PhD
Ambuj Kumar, MD, MPH
Rahul Mhaskar, PhD

Florida Department of Health (FDOH)
Cheryl Clark, DrPH
Karen Freeman, MPH, MS
Marie Bailey, MS

Florida Agency for Health Care Administration (AHCA)
Collaborator: Adrienne Henderson, MPH

Collaborator: Estrellita "Lo" Berry, MA

Materials developed by the Florida grantee

Peer-Reviewed Publications
Salemi JL, Tanner JP, Bailey M, Mbah AK, Salihu HM. "Creation and Evaluation of a Multi-layered Maternal and Child Health Database for Comparative Effectiveness Research." Journal of Registry Management, 2013.

Salihu HM, Salinas-Miranda AA, Mogos MF. "The Missing Link in Preconceptional Care: The Role of Comparative Effectiveness Research." Maternal and Child Health Journal, 2013.

Salinas-Miranda AA, Nash MC, Salemi JL, Mbah AK, Salihu HM. "Cutting Edge Technology for Public Health Workforce Training in Comparative Effectiveness Research." Health Informatics Journal, 2013.

Salemi JL, Comins M, Chandler KC, Mogos MF, Salihu HM. "A Practical Approach for Calculating Reliable Cost estimates from Observational Data: Application to Cost-Effectiveness Analysis in Maternal and Child Health." Applied Health Economics and Health Policy, 2013.

Salihu HM, Salemi JL, Nash MC, Chandler K, Mbah AK, Alio AP. "Assessing the Economic Impact of Paternal Involvement: A Comparison of the Generalized Linear Model Versus Decision Analysis Trees." Maternal and Child Health Journal, 2014.

Mogos MF, August EM, Salinas-Miranda AA, Sultan DH, Salihu HM. "A Systematic Review of Quality of Life Measures in Pregnant and Postpartum Mothers." Applied Research in Quality of Life, 2013.

Data Collection
Linking Maternal and Child Health Data to Create a Comprehensive Longitudinal Dataset: The Florida Experience (PDF file, 502 KB; HTML)
Presentation that illustrates issues involved in linking maternal and child health data, provides a comparison of the capabilities of various software data linking products, and discusses a customized SAS macro that is being used for linking.

Hawaii Grantee

GRANT SUMMARY: Collaborators from The Queen's Medical Center and Hawaii Health Information Consortium have enhanced the clinical content of Hawaii's statewide hospital discharge database by adding laboratory results and have furthered development of a master patient identifier to link and track patients across hospitals throughout the state. The researchers demonstrated the viability of the enhanced database by performing a comparative effectiveness research study to examine the outcomes of care for patients treated by hospitalists compared with patients treated by nonhospitalists. The end result is an enduring infrastructure that will improve research and quality.

Hawaii Contacts

The Queen's Medical Center
Project Director: Todd Seto, MD

Hawaii Health Information Corporation
Principal Investigator: Jill Miyamura, PhD
Project Manager: Christine Reuschel, BSBA
Data Warehouse Manager: Michael Murata, BBA

Materials developed by the Hawaii grantee

Data Collection
Enhancing Hawaii Hospital Information Content: Data Acquisition (PDF file, 1.5 MB; HTML)
Document that details the grantee's process for acquiring laboratory data and includes implementation guidelines as well as appendices containing data specifications for different data standards such as HL7 and ASCII.

Enhancing Hawaii Hospital Information Content: High-Level Analysis of Transmitted Laboratory Data (PDF file, 585 KB; HTML)
Document that details the grantee's experience with standardizing their laboratory data feeds, dealing with missing data, and other data quality issues.

Enhancing Hawaii Hospital Information Content: Linking Lab Data to Inpatient Discharge Data (PDF file, 550 KB; HTML)
Document that details the grantee's experience linking 32 specific laboratory test results from 2008-2011 with Hawaii Health Information Corporation's (HHIC) hospital discharge data.

HL7 Integration Engine Vendor Evaluation Template (PDF file, 397 KB; HTML)
This template can be used by organizations when searching for and comparing the qualifications of vendors to implement data infrastructure changes. The organization's leadership need to ensure that the vendor has a clear understanding of the project; a sound, evidence- and experience-based approach; and the proper personnel and organizational qualifications to conduct the task.

HL7 Implementation Guide (PDF file, 830 KB; HTML)
Specifications for laboratory observation reporting using HL7.

ASCII Implementation Guide (PDF file, 197 KB; HTML)
Specifications for laboratory observation reporting using ASCII file format.

Summary of Required Laboratory Tests and LOINC (PDF file, 257 KB; HTML)
Document that contains a list of all required tests and requests that the user identify the vendor or internal hospital operation responsible for reporting the results of each test.

Project Initiation and Planning
Enhancing Hawaii Hospital Information Content: Hospital Engagement (PDF file, 924 KB; HTML)
Document that details the grantees's process for securing hospital participation and communication strategies, and includes examples of letters of support, participation agreements, and presentations to educate stakeholders about the project.

Incorporation of Laboratory Results into Statewide Hospital Data (PDF file, 1.1 MB; HTML)
Overview of the HI grantee's project.

Minnesota Grantee

GRANT SUMMARY: The Minnesota Hospital Association (MHA), in collaboration with Michael Pine Associates and the Mayo Clinic Division of Health Care Policy and Research, has augmented the current MHA clinically enhanced administrative hospital discharge database with laboratory data from additional hospitals, and introduced hospital pharmacy data and Minnesota death certificate data to the database. The end goal of the project was to use these data to facilitate rich comparative effectiveness analysis and to enhance the scope and quality of the Minnesota hospital discharge database.

Minnesota Contacts

Minnesota Hospital Association (MHA)
Mark Sonneborn
Joe Schindler
Project Coordinator: Jaclyn Roland
Database Designer: Neil Negstad

Michael Pine and Associates, Inc.
Principal Investigator: Michael Pine MD, MBA
Data Consultants:
Donald Fry, MD
Kay Whitman
John Obert
David Locke
Linda Hyde
Agnes Reband

Slingshot Informatics
Investigator: David Nelsen
Database Analysts:
Sue Potter
Josh Engle
Ben Germann

Rochester, Mayo Clinic
Principal Investigator: James Naessens
Ahmed Rahman
Stephanie Peterson
Matt Johnson
Diane Olson
Sue Visscher
Kyle Koenig

Materials developed by the Minnesota grantee

Project Initiation and Planning
Lab/Pharmacy Data Sign up and Commitment Letter (PDF file, 58 KB; HTML)
Cover letter introducing the Hospital Commitment Form.

Hospital Commitment Form (PDF file, 47 KB; HTML)
Mechanism for interested hospitals to sign up to participate in a data enhancement project.

Next Steps to AHRQ Lab/Pharmacy Participation (PDF file, 14 KB; HTML)
Sets forth hospitals' initial steps for project participation.

MHA/AHRQ Clinically Enhanced Data Project (PDF file, 352 KB; HTML)
Flyer that provides an overview of goals of the project and benefits to hospitals' participation.

Deliverables for Participating Hospitals (PDF file, 11 KB; HTML)
List of the customized outputs from the MHA/AHRQ project that will benefit participating hospitals.

Data Collection
Data Acquisition and Transmission: Pharmacy Data (PDF file, 113 KB; HTML)
Presentation for the Acute Heart Failure project.

Phase 1 Pharmacy Data Collection (PDF file, 194 KB; HTML)
Overview of the hospital-, patient- and drug-level data to be collected for the Acute Heart Failure project.

Pharmacy Data Specifications and Formats (PDF file, 122 KB; HTML)
Detailed formatting guidelines for transmission of pharmacy data.

Matching Patients across Institutions without Definitive Patient Identifiers (PDF file, 591 KB; HTML)
Discussion of death certificate matching using ZIP codes.

HL7 Drug Order Examples (PDF file, 163 KB; HTML)
Samples of minimum required HL7 segments for drug order data.

LOINC Overview and Instructions (PDF file, 102 KB; HTML)
Document that provides an instruction manual for specifying LOINC® mapping. The document includes a background description of LOINC, instructions for submission, frequently asked questions, and sample data in a LOINC Code Worksheet.

LOINC Worksheet (XLS file, 50 KB; HTML)
Spreadsheet that lists common lab tests and asks the hospital to provide specimen type, units, normal range, etc. for each test. Instructions provided in LOINC Overview and Instructions.

Participating Hospital Questionnaire (PDF file, 340 KB; HTML)
Inquires about content and format of hospital lab and pharmacy data and how the hospital plans to send it to the state data organization. (Developed by the Minnesota grantee)

Lab Tests Desired for AHRQ Project (XLS file, 33 KB; HTML)
Spreadsheet that lists lab test data requested from hospitals participating in the MN project. (Developed by the Minnesota grantee)

Lab Data Acquisition and Transmission (PDF file, 206 KB; HTML)
Presentation that provides overview of data transmission process and requirements.

Lab Data Requirements (PDF file, 203 KB; HTML)
Guides hospitals in understanding, formatting, and applying inclusion criteria for each data element to be reported.

New Jersey Grantee

GRANT SUMMARY: An innovative partnership between academic researchers at Rutgers Center for State Health Policy and the New Jersey Department of Health and Senior Services has created a data infrastructure that bridges pre-hospital and hospital care using electronic patient care records for emergency medical services transports in New Jersey. These data linked all-payer hospital discharge data and death certificates to support a wide range of studies on interventions that involve prehospital and hospital services. A comparative effectiveness study of outcomes after provision of therapeutic hypothermia for initial survivors of out-of-hospital cardiac arrest has illustrated the value of the data.

New Jersey Contacts

Rutgers University, Center for State Health Policy
Principal Investigator: Derek Delia, PhD

Materials developed by the New Jersey grantee

Peer-Reviewed Publications
DeLia D, Wang HE, Kutzin J, Merlin M, Cantor JC. "Post-Cardiac Arrest Therapeutic Hypothermia in New Jersey Hospitals: Analysis of Adoption and Implementation." Therapeutic Hypothermia and Temperature Management, 2012.

Data Collection
Report from the Rutgers Center for State Health Policy

Presentation reporting survey results of therapeutic hypothermia use in NJ hospitals.

New York Grantee

GRANT SUMMARY: The New York State (NYS) Department of Health; School of Public Health, SUNY–Albany; and Michael Pine Associates have worked together to link administrative data from NYS' Statewide Planning and Research Cooperative System (SPARCS) acute care hospital discharge database to laboratory test results from facilities that perform coronary artery bypass graft (CABG) surgery or elective percutaneous coronary interventions (PCI). To assess the value of the resulting clinically enhanced database, the research team has compared risk-adjusted outcomes and analyses of the appropriateness of alternative revascularization procedures using the clinically enhanced administrative database with analyses performed using specialized CABG and PCI registries. Another goal of the project was to determine whether laboratory test results will enhance the ability of the cardiac registry data to risk-adjust patient outcomes

New York Contacts

New York Department of Health
Principal Investigator: Barbara Denison, MD
Project Coordinator: Mary Lou Caprara

Michael Pine and Associates, Inc.
Co-investigator: Michael Pine, MD, MBA
Data Consultants:
Donald Fry, MD
Kay Whitman
John Obert
David Locke
Linda Hyde
Agnes Reband

University at Albany, School of Public Health
Collaborator: Edward L. Hannan, PhD

Materials developed by the New York grantee

Project Initiation and Planning
Contact Information for Submission of Clinical Laboratory Data (PDF file, 276 KB; HTML)
Form for recording specific staff responsible for listed laboratory data submission roles and responsibilities.

Potential Solutions to Lab Data Extraction (PDF file, 194 KB; HTML)
The process of extracting laboratory test information from an organization's database can require considerable cooperation between IT personnel, healthcare leadership, and data analysts. This document carefully describes each data selection step and identifies potential difficulties and solutions to each.

Frequently Asked Questions for Coronary Procedures Project (PDF file, 296 KB; HTML)
Provides answers to questions asked by administrative staff tasked with carrying out new protocols. Preparing this type of document in advance of project initiation can help hospital leadership think through their plans and, distributed as a handout, can relieve common concerns of hospital staff.

Instructions for Extracting and Submitting Lab Data (PDF file, 832 KB; HTML)
Overview of the data collection process and details of required data format.

Coronary Procedures Study: An Outline for Labs (PDF file, 575 KB; HTML)
Document that provides a quality assurance protocol for setting up data transmission. It identifies naming conventions, folder structures, file formatting options, and extraction and submission protocols.


Internet Citation: Clinical Content Enhancement Toolkit. Healthcare Cost and Utilization Project (HCUP). July 2016. Agency for Healthcare Research and Quality, Rockville, MD.
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Last modified 7/18/16