Comparison of methodologies for calculating quality measures based on administrative data versus clinical data from an electronic health record system: implications for performance measures

J Am Med Inform Assoc. 2007 Jan-Feb;14(1):10-5. doi: 10.1197/jamia.M2198. Epub 2006 Oct 26.


New reimbursement policies and pay-for-performance programs to reward providers for producing better outcomes are proliferating. Although electronic health record (EHR) systems could provide essential clinical data upon which to base quality measures, most metrics in use were derived from administrative claims data. We compared commonly used quality measures calculated from administrative data to those derived from clinical data in an EHR based on a random sample of 125 charts of Medicare patients with diabetes. Using standard definitions based on administrative data (which require two visits with an encounter diagnosis of diabetes during the measurement period), only 75% of diabetics determined by manually reviewing the EHR (the gold standard) were identified. In contrast, 97% of diabetics were identified using coded information in the EHR. The discrepancies in identified patients resulted in statistically significant differences in the quality measures for frequency of HbA1c testing, control of blood pressure, frequency of testing for urine protein, and frequency of eye exams for diabetic patients. New development of standardized quality measures should shift from claims-based measures to clinically based measures that can be derived from coded information in an EHR. Using data from EHRs will also leverage their clinical content without adding burden to the care process.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Blood Pressure
  • California
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / therapy*
  • Fee-for-Service Plans
  • Glycated Hemoglobin A / analysis
  • Humans
  • Insurance Claim Review
  • Medical Records Systems, Computerized*
  • Medicare
  • Outcome and Process Assessment, Health Care / methods*
  • Outcome and Process Assessment, Health Care / standards
  • Proteinuria / diagnosis
  • Quality Indicators, Health Care*
  • Quality of Health Care


  • Glycated Hemoglobin A