A SMART App To Track And Report Stroke Cases To Reduce Readmissions

Project Name: A SMART App To Track And Report Stroke Cases To Reduce Readmissions

Project Results: To view the presentation from CHIIC’s May 2017 forum, click hereCdc-pdf

Project Status: Awarded

Point of Contact:Arunkumar Srinivasan

Center:National Center for Chronic Disease Prevention and Health Promotion

Keywords:SMART, HL7, FHIR, EHR, Coverdell, Stroke Registry, Core Data Elements, Technical Standards, API

Project Description: The Paul Coverdell National Acute Stroke Registry initiated in 2004 is a state-based registry to improve quality of stroke inpatient care.  The CDC funds states to evaluate stroke related data and guide quality improvement interventions with more than 250,000 patients benefiting from this quality improvement since its creation. Over time, Coverdell has expanded to measure, track and improve the quality of care for patients from the onset of stroke symptoms through rehabilitation to recovery. In order to get an adequate understanding of which events are more likely to lead to readmission, the Coverdell project expanded beyond inpatient reporting in the current FOA to collect information during the following intervals 1) patients are picked up by EMS and taken to the hospital and 2) the patient transitions from the hospital to their next care setting (e.g. home, inpatient rehabilitation, nursing home).

Currently, inpatient data is collected for Coverdell using a QuintilesExternal web-based interface called Get with the GuidelinesExternal or through the creation of a state-based interface and data is sent to CDC quarterly from the states. While pre-admission data residing in an EMS system needs extraction, major challenges exist in the post discharge reporting. The post discharge data is typically collected by a nurse or stroke coordinator by calling the patients by phone 2-30 days after discharge from the hospital post-stroke.  During these calls, the patient is asked approximately 30 questions about topics such as medication adherence, falls, patient follow up visits with their healthcare providers, and the effectiveness of patient education before their discharge etc. Expanding the current Get with the Guidelines system for post discharge is arduous and cost prohibitive. Furthermore, the memorandums of understanding also require that data collected through Get with the Guidelines be the property of the American Heart Association. Recently Division of Heart Disease and Stroke Prevention (DHDSP) partnered with Epi Info (supported by a CHIIC 2015 grant) to prototype a secure multi-site web-based approach. This solution meets threshold requirements for a low-cost solution with no dependency on hospital systems. However, the workflow remains expensive and error prone as nurses must enter data into a web form for state submission and then re-enter into the local EHR system for hospital use.

Project:  The Office of Informatics and Information Resource Management (OIIRM) in collaboration with DHDSP is applying for a grant to test a standards-based approach towards collecting and reporting data from/to EHR, including in-patient and post-discharge data. This would provide a flexible, and effective alternative to the Quintiles solution, solve the double-data-entry problem, and provide a scalable solution to support future Coverdell surveillance across a wider population of hospitals within each grantee jurisdiction. We are requesting $50,000 to support an evaluation of the EHR agnostic SMART (http://smarthealthit.org/External) technology platform and conduct a gap analysis of the HL7 FHIR resources to support reporting from both inpatient and post discharge setting. The outcomes of the evaluation will inform if SMART is a suitable technology stack for Public Health to support this kind of data collection from EHR. The proposal seeks to design a standalone SMART app with suitable security permissions for the nurse practitioners to report inpatient stroke cases and the 2-30 day follow-up call information. The app will utilize standard HL7 FHIR resources to prepopulate forms using EHR data and support the nurse practitioner’s workflow to report cases to public health (PH). The post discharge follow up information could also be sent back to the EHR as a part of the patient history. This also allows to validate if the HL7 FHIR based SMART platform will enable the feedback loop to the point of care that is noticeably missing in the current PH-Clinical partnership.

Proposed Deliverables:

  1. Gap analysis of HL7 FHIR resources and Coverdell Reporting Data Elements
  2. Evaluation of SMART platform to meet the Coverdell Reporting Workflow
  3. Design document with wireframes of a SMART APP for Coverdell reporting


  1. Guidance for state awardees on how best to implement EHR based secure patient-level data collection system for public health surveillance.
  2. Deliver a seamless EMR integration of a PH reporting workflow and the clinical workflow by adopting a build once and use many concept.
  3. Ability to close the feedback loop to clinical setting by writing back post management data into the EMR using the standardized approach
  4. Increase data quality, timeliness and completeness of stroke data reporting
  5. This funding would provide language which would help ensure accountability of agency funding and improve the quality of our 30 day surveillance data.  This in turn will facilitate the creation and implementation of useful quality improvement interventions which will directly impact patient readmissions and outcomes.
  6. The technical specifications created through this funding could be tailored to suit the needs of other programs across the agency for use in their funding announcements thereby ensuring accountability, reducing redundancies, addressing system usability and data security, improving the quality of surveillance data, and providing maximal impact.

For more information about this project, please contact the CHIIC at chiic@cdc.gov or Brian Lee at Brian.Lee@cdc.gov

Page last reviewed: February 15, 2019