Non-Epic Clinical
Onboarding Guide
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Contents
About This Guide .......................................................................................................................... 4
Minimum Data Requirements ....................................................................................................... 4
Minimum Timeframe Requirements .......................................................................................... 4
Patient Information ................................................................................................................... 5
Basic Case Information............................................................................................................. 5
Preoperative Documentation .................................................................................................... 5
Intraoperative Documentation .................................................................................................. 6
Postoperative Documentation ................................................................................................... 7
Outcomes ................................................................................................................................ 7
Charge Capture & Administration .............................................................................................. 7
Labs......................................................................................................................................... 7
Other Data Elements to Include .................................................................................................... 8
Patient Information ................................................................................................................... 8
Time Documentation ................................................................................................................ 8
Preoperative Data ..................................................................................................................... 8
Intraoperative Data ................................................................................................................... 9
Postoperative Data ................................................................................................................. 10
Events .................................................................................................................................... 10
Medications ........................................................................................................................... 11
Medication Details .............................................................................................................. 11
Intake and Output ................................................................................................................... 12
Intake ................................................................................................................................. 12
Output ................................................................................................................................ 12
Outcomes .............................................................................................................................. 12
Sta .......................................................................................................................................... 13
Optional/Supplemental Data Extracts ......................................................................................... 14
Microbiology .......................................................................................................................... 14
Patient Attributes.................................................................................................................... 14
Variable Basics – Any Electronic Health Record (EHR).................................................................. 15
Storing Variables in Modules ................................................................................................... 16
Appendix A – Common Issues Encountered ................................................................................ 17
Any EHR ................................................................................................................................. 17
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Cerner ................................................................................................................................... 17
CompuRecord ........................................................................................................................ 17
MetaVision ............................................................................................................................. 18
Appendix B – Q&A Cerner Sites ................................................................................................... 19
Appendix C – MPOG Technical Guides ........................................................................................ 21
Technical Guides .................................................................................................................... 21
Supplemental Extract Specifications ....................................................................................... 21
Additional Technical Tools ....................................................................................................... 21
Glossary .................................................................................................................................... 22
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About This Guide
This guide is intended for site teams preparing data from non-Epic electronic health record systems
for participation in the Multicenter Perioperative Outcomes Group (MPOG). Use it to understand
minimum data requirements, identify additional data elements that support research and quality
improvement, prepare variables for mapping, and review common technical considerations.
Requirements and recommendations: Content identified as required represents the minimum
information needed for MPOG participation or applies to the sites specifically noted.
Recommended and optional content can improve data completeness and support additional uses
but is not required unless otherwise stated.
Support and exceptions: For technical assistance, contact the MPOG Help Desk at
support@mpog.zendesk.com. Discuss site-specific workflows, exceptions, or questions about how
a requirement applies to your data with your assigned MPOG Clinical Informatics Specialist.
Minimum Data Requirements
This section summarizes the minimum data elements and timeframes required for MPOG
participation. Use it to confirm that the site’s extract includes the core patient, case, clinical,
billing, and laboratory information needed for onboarding and ongoing data submission. Unless
otherwise noted, these items represent minimum requirements; sites are encouraged to submit
additional relevant data when available. The complete requirements are available on the MPOG
Minimum Data Requirements webpage.
Minimum Timeframe Requirements
These are the minimum timeframe requirements for participation in the Multicenter Perioperative
Outcomes Group (MPOG).
• Flowsheet and physiologic data
o 4 hours before anesthesia start through 6 hours after anesthesia end
Documentation may occasionally fall outside this timeframe
• Labs
o 365 days before through 365 days after the Date of Service (DOS).
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Patient Information
The following patient identifiers are required for protected health information (PHI) scrubbing and
Privacy Preserving Record Linkage (PPRL).
These identifiers are stored only in the site’s local
database. They are not accessible to MPOG and are not sent to the MPOG Coordinating Center.
• Full name
• Date of birth
• Social security number
• Medical record number
Additional patient information should include:
• Gender, which may include sex assigned at birth, legal sex, or gender identity
Basic Case Information
The following case-level details provide the basic information needed to identify, categorize, and
interpret each submitted case.
• Admission type
o This is determined by how the case was scheduled. We have developed a
specification for an optional supplemental extract for ADT
(Admission/Discharge/Transfer) data that can be used to show admission status
changes.
• Age at time of operation
• Facility and operating room type
• Primary procedure text
• Primary diagnosis text
Preoperative Documentation
The following items are the minimum preoperative documentation requirements. Institutions are
strongly encouraged to contribute additional data elements when available.
• ASA status
•
Height documented within 30 days before the procedure
•
Weight documented within 30 days before the procedure
•
Basic cardiac, pulmonary, endocrine, renal, hepatic, and immunologic comorbidities
documented in the preoperative history and physical
o
Basic comorbidity data is required for all Blue Cross Blue Shield funded sites
(Michigan sites only).
o
The applicable history and physical timeframe depends on the site’s data extract.
Some systems may carry forward earlier diagnoses or preoperative information.
Otherwise, documentation should be associated directly with the case.
• Physiologic data
o Use separate variables for systolic blood pressure, diastolic blood pressure, heart
rate or pulse, temperature, temperature route, and other physiologic data.
• Home medications
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o Home medications may use one Variable ID and one Variable Name rather than
separate identifiers for each medication. Include the medication name, dose, and
frequency in the variable’s Value.
Grouping home medications under one Variable ID and Variable Name can
reduce the number of variables that require monthly mapping.
o The home medications should be in the Observation Type mapping type.
o The following example shows how home medications are represented at one
participating non-Epic site:
Intraoperative Documentation
The following intraoperative data elements capture key case times, clinical observations,
treatments, sta activity, and physiologic monitoring during the procedure.
• Case times
o Anesthesia Start/Anesthesia End
o Procedure Start/Procedure End
o Incision time
o Post-Anesthesia Care Unit (PACU) In/PACU Out
Include Phase II and Phase III as applicable
• Fluid inputs and outputs
o Fluids should include the documented start and end times
• Medication administrations
• Observational and procedure notes
o Examples include tourniquet up, bypass start, intubation notes
• Point of care labs
• Sta tracking
• Sign-in/outs for anesthesia attendings
• Vital signs
o machine captured minute-by-minute or manually entered
• Train of Four
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Postoperative Documentation
The following postoperative data elements support review of recovery-area physiologic data and in-
hospital outcomes.
• Physiologic data
o Separate Invasive and Non-Invasive Blood Pressure
o Separate systolic blood pressure and Diastolic blood pressure
• In hospital all-cause mortality
Outcomes
• In-hospital mortality
o This data generally reflects deaths known to the hospital, most commonly deaths
occurring during the hospital stay. A small number of instuons may also contribute
data from a death registry.
• Postoperave Nausea and/or Voming (PONV)
Charge Capture & Administration
• Hospital discharge billing codes
• Professional fee anesthesia billing codes
• Primary payer
• Timeframe to be included:
o No maximum timeframe applies; however, professional fee procedures are
generally limited to a single day.
• Discharge diagnoses
o No maximum number of discharge diagnoses applies. The extract should include all
diagnoses documented for the hospital stay.
Labs
• All labs resulted +/- 365 days from the date of procedure
o This can be extended if the patient has another case.
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Other Data Elements to Include
Every anesthesiology information system has a dierent set of data elements; therefore, it would be
impossible to categorize a complete list of data elements. The following list includes data elements
that are commonly used in Anesthesia, MPOG Research, and MPOG QI Measures.
Patient Information
• Race and Ethnicity (Where applicable by law)
• Gender
o Sex Assigned at Birth
o Legal Sex
o Gender Identity
o Sexual Orientation
• Smoking/Tobacco Use Status
• Last Menstrual Period
• Past Medical History
• Past Surgical History
• Previous Problems with Anesthesia
• Patient Status: inpatient, outpatient
Time Documentation
Each variable should have associated documentation times. There are two times that are typically
associated with the variables: Entered Time and Observed Time.
• Entered Time: The time that the variable was documented.
• Observed Time: The time that the procedure/event/care was performed (not necessarily the
same as when it was documented).
o If observed time is not documented, MPOG will default to using the time the note
was documented (entered time).
Preoperative Data
• Review of Systems
• History and Physical
• Preop Notes
• Preop Events
• Anesthesia Plan
• History of substance use (including tobacco, marijuana, alcohol, drugs, vape)
• Emergency status – This can be stored as a separate field or always with the ASA status.
This variable should be in Observation Type.
• Preop documentation (including nursing notes)
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Intraoperative Data
• Physiologic data
o Systolic Blood Pressure (invasive, non-invasive, continuous non-invasive)
o Diastolic Blood Pressure (invasive, non-invasive, continuous non-invasive)
o Heart Rate/Pulse
From EKG
From SpO2
o Respirations
o Temperature
o Temperature Route/Source
o Oxygen Saturation (SpO2)
o Train of Four
o Perfusion
o Pain
• Inhalational Agents administered
o Sevoflurane, Desflurane, Isoflurane, Nitrous
Inspired %, Expired %, flows
o Oxygen
o Air
• Ventilator data
o PEEP
o Tidal Volume actual
o Tidal Volume set
o Peak Pressure
o Pressure Control
o Ventilator Mode
o Respiratory Rate Set
o Respiratory rate Limit
o Respiratory Rate Actual
o Ventilator I:E Ratio
o Ventilator I:E Ratio I-Component
o Ventilator I:E Ratio E-Component
• Intraoperative Provider Hando (Attending to Attending, Certified Registered Nurse
Anesthetist [CRNA] to CRNA, Resident to Resident, AA to AA, etc.) You do not need to
separate intraop hando documentation based on the role giving or receiving hando.
• Intraoperative Events
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Postoperative Data
• PACU Notes
• PACU Events
o PACU In/Out times
o Phase I, Phase II, Phase III times
o Transfer to floor times
• Postoperative Physiologic data
• Postoperative Hando (to PACU, ICU, etc.)
• Postoperative Destination (ICU, PACU, etc.)
Events
The following examples show commonly documented perioperative events and their related
details. Events such as intubation, extubation, and line placement are usually mapped under
Observation Type. Details associated with an event, such as endotracheal tube size or tube type,
are usually mapped under Observation Detail Type.
• Airway (ETT, LMA, tracheostomy)
o Intubation
o ETT Size
o Extubation/removal time
o LMA Placement
o LMA size
o LMA Removal time
• Blocks
o Spinal
o Epidural
o Labor epidural
o Neuraxial Block
o Regional Block
o Paresthesia
o Combined Spinal/CSE
o Block Type
o Needle Size (gauge)
o Block Location
o Technique
• OB notes
o Frequency of contractions
o Duration of contractions
o Delivery of newborn
o Delivery of placenta
o Fetal Heart Rate
o Apgar Score
o Uterine Incision
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• Arterial Line Placement
o Arterial Line Insertion
o Arterial Line location
o Catheter size
• Cardiopulmonary Bypass
o Start
o End/Stop
o Bypass Circuit Pump
o Arterial Cannula insertion
o Arterial Cannula removal
o Circulatory Arrest Start
o Blood Pressure Lowered Therapy
o Systemic Cooling
o Cardioplegia Stop
o Aortic Clamp On
o Aortic Clamp O
o Ice On Head
o Ice O Head
Medications
These variables should be in the Administration Type (Inputs/Outputs/Meds) mapping type. These
medications are typically given in the hospital and do not include home medications. This should
include medications administered during preop, intraop, and postop.
• Insulin
• Antibiotics
• Antiemetics
• Anesthesia Medications
• Steroids
• IV Fluids
• Pain medications
• Vasopressors
• Inotropes
• Anti-hypertensives
Medication Details
• Routes
• Start and end times for infusions/IV fluids
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Intake and Output
These variables should be in the Administration Type (Inputs/Outputs/Meds) mapping type.
Intake
• Transfusion of blood products
o Packed Red Blood Cells (PRBCs)
o Plasma
o Cell Saver
o Platelets
o Whole Blood
o Autologous/homologous
Output
• Estimated blood loss (EBL)
• Emesis amount
• Urine
Outcomes
These variables should be under the Observation Type mapping type. Outcomes include but are not
limited to:
• Postoperative Nausea and Vomiting (PONV)
• Reintubation
• Diicult intubation
• Cardiac arrest
• Postoperative Hypothermia
• Dysrhythmia
• Dental Injury
• Failed/Inadequate block
• Failed/Inadequate neuraxial technique
• Laryngospasm
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Sta
Include all sta roles involved in the patient’s perioperative care, as applicable. The two-column list
that follows provides examples of sta roles that may appear in the data. All anesthesia providers
are required to have a sign-out time. If a sign-out time was not documented, Anesthesia End may
be used as the sign-out time.
• Anesthesiologist (Attending,
Secondary)
• CRNA
• Student Registered Nurse Anesthetist
(SRNA)
• Anesthesia Assistant
• Anesthesia Resident
• Anesthesia Technician
• Anesthesia Fellow
• Anesthesia Clinical Monitoring
Technician
• Anesthesia Medical Student
• Surgical Attending/Proceduralist
(primary)
• Surgical Attending/Proceduralist
(secondary)
• Surgical Resident
• Surgical Resident on Anesthesia
Rotation
• First Assistant
• Scrub
• Circulating Nurse
• Preop Nurse
• Postop Nurse
• Nurse
• Observer
• Student
• Perfusionist
• Perfusion Student
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Optional/Supplemental Data Extracts
Microbiology
Purpose: The Microbiology Labs module captures specimen, organism, and antibiotic
susceptibility data that is not included in the standard Labs file.
File specification: Sites interested in submitting Microbiology Labs data can review the file
specification on the Downloads page.
Support: For more information, contact the MPOG Help Desk at support@mpog.zendesk.com.
Patient Attributes
Requirement: Patient Attributes data is required for Blue Cross Blue Shield-funded sites in
Michigan and optional for sites outside Michigan.
Purpose: This information may support research and quality improvement related to healthcare
disparities.
More information: If your site is interested in submitting Patient Attributes data, review the file
specification on the Downloads page. For assistance, contact the MPOG Help Desk at
support@mpog.zendesk.com.
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Variable Basics – Any Electronic Health Record (EHR)
• AIMS variable: A data element from the site’s electronic health record that is defined in the
extract. Similar documentation is grouped under one variable, such as non-invasive systolic
blood pressure, invasive systolic blood pressure, and non-invasive diastolic blood pressure.
Each variable has a distinct Variable ID and Variable Name.
• Value: The text or numeric information documented for a variable in the EHR.
o For example, the AIMS variable “ON CPB” represents the start of cardiopulmonary
bypass. The Value should describe the event, such as “Cardiopulmonary bypass
initiated,” rather than repeat the date and time. The event time should be recorded
as the Observed Time.
Recommended format: This image shows “CPB Initiated” in the Value field instead
of a date and time.
• Observed Time: The time the procedure, event, or care was performed. If Observed Time is
not documented, MPOG uses the time the note was documented, or Entered Time.
• Entered Time: The time the variable was documented.
• MPOG Concept: The standardized MPOG term assigned to the variable during Variable
Mapping.
o Note: Variable mapping is completed in collaboration with the MPOG Clinical
Informatics Specialist and requires a scheduled meeting.
• Variable ID: Each variable should have a unique Variable ID. Home medications may be
grouped under one Variable ID and Variable Name, but all other variables should use unique
identifiers.
• Blood pressure: Use separate variables for systolic and diastolic blood pressure. Also
separate variables by measurement type: invasive, non-invasive, and continuous non-
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invasive. For example: Variable ID 1234; Variable Name, Non-invasive Systolic Blood
Pressure. Physiologic variables should use the Observation Type mapping type.
• Regional block notes: Store details such as single-shot technique and patient
identification as Observation Detail Type under the peripheral nerve block variable.
Storing Variables in Modules
MPOG organizes related data into modules based on the type of information submitted. Use the
following table to identify the module that stores each common data element. The examples are
intended as a quick reference and may not include every data element available in a site’s extract.
Module
Data Included
Cases
Date of Service
Operating Room
Admission Type
Surgical Service
Procedure Text
Diagnosis Text
Organizations used to select the appropriate
local MPOG database
Diagnoses
Hospital Discharge Diagnosis and Professional
Fee Diagnosis Codes
Hospital Mortality
Date of Death (in hospital only)
Labs
Formal Labs and Point-of-care Labs
Patients
Patient Name
MRN
Gender
Ethnicity
Race
Payers
Insurance and other payer data
PeriopAdministrations
Fluids and Medications
PeriopObservations
Preoperative Notes
Intraoperative Notes
Monitor Data
Procedures
Professional Fee Procedure Codes
Hospital Discharge Procedure Codes
StaTracking
Sta sign ins/outs and role (e.g. Attending)
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Appendix A – Common Issues Encountered
Any EHR
• Issue: What do I do when the file is too big to import? Should I split it into multiple files?
o Resolution: You cannot “split” files. All that does is overwrite data since the system
assumes the date you are importing is complete. You will need to re-extract the
aected dates in smaller ranges, keeping individual files under 2GB in size.
• Issue: My Institution changed the name of a location, and the data is not coming over to our
local MPOG App Suite. How do I fix it?
o Resolution: This issue may occur when an institution changes a location name.
Local technical support can enable the renamed location in the database so data
can resume processing. If the location is not enabled, previously available data may
gradually disappear as subsequent 30-, 90-, and 365-day extracts are processed.
Contact the MPOG Help Desk (support@mpog.zendesk.com) for instructions
before enabling a location.
When a location is enabled, it may take 24-48 hours for the system to
process that data. You will not see the new data until after it has been
processed.
Note: Do NOT enable locations without first contacting MPOG.
Cerner
• Issue: Height and/or weight are missing from banner in Case Viewer but are visible in the
H&P section.
o Resolution: Remove the units of measurement from the height and weight values. It
should be numeric only, if there is additional text, it won't capture it correctly.
• Issue: Height and/or weight are mapped but are not showing up in Data Diagnostics.
o Resolution: Remove the units of measurement from the height and weight values. It
should be numeric only, if there is additional text, it won't capture it correctly.
CompuRecord
• CompuRecord allows providers to document similar data in dierent places. Some notes
that we expect to see as parent/child notes can show up as separate parent notes (i.e. art
lines, intubations, etc.).
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MetaVision
• Labor Epidurals did not have anesthesia start and anesthesia end documented. Site had to
create a “pseudo” event pair to indicate anesthesia start and anesthesia end. Site used the
MetaVision Labor Timer for Anesthesia Start and Anesthesia End for these cases.
• Site did not have explicit Surgery Start and Surgery End times for endoscopy cases, but do
have Scope In and Scope Out. Site mapped the Scope In/Out events to AACD Procedure
Start/Finish Date Time (MPOG Concept IDs: 50006/50007).
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Appendix B – Q&A Cerner Sites
One of our Active Cerner sites met with one of our interested Cerner sites and discussed the
process of joining MPOG. Identifying information has been removed. Even though this discussion
was between two Cerner sites, it can be used as a reference for other EHRs as well.
Question 1: What was the initial challenge faced by the team with MPOG's data requirements?
Answer 1: The team initially needed to adjust from working with a limited set of required fields to
evaluating the broader MPOG data set. Clear guidance and a phased approach helped the team
understand and integrate the requested data elements.
Question 2: How does MPOG handle data from dierent institutions with varying definitions?
Answer 2: MPOG uses standardized concepts and Variable Mapping to align equivalent fields from
institutions that use dierent terminology. For example, one system may use “provider” while
another uses “clinician.”
Question 3: What infrastructure setup was required for the project?
Answer 3: The team needed to set up servers to store data locally, which took about six months.
The IT Support Person played a crucial role in pulling data from various databases and writing the
necessary code, supported by an analyst with clinical experience.
Question 4: What role did the Clinical Data Analyst play in the project?
Answer 4: The analyst, who was also a nurse, was instrumental in interpreting clinician needs into
technical requirements and assisting with the data mapping process.
Question 5: How does MPOG ensure data validation before submission?
Answer 5: MPOG requires sites to validate data locally before submitting it to MPOG Central. The
MPOG App Suite supports this validation process, which should be completed monthly by an
assigned team member, such as a research nurse.
Question 6: What is the process for determining which anesthesia and related data to extract?
Answer 6: The site team reviews MPOG’s data requirements and works with MPOG to determine
which data should be extracted from its systems.
Question 7: What qualifications are essential for a developer working on this project?
Answer 7: The developer should have experience with extract, transform, and load processes;
scripting; and, when applicable, Cerner. Collaboration with the local IT team is important for
system access and technical guidance.
Question 8: How did the IT Support Person handle the technical aspects of the project?
Answer 8: The IT Support Person handled the programming side, using Python and SQL, and relied
on support from the IT team to understand Cerner's schemas and navigate the data model.
Question 9: How important is IT support for the project's success?
Answer 9: IT support is crucial for navigating Cerner's extensive and complex data model. The
developer will need guidance to find specific data fields and ensure accurate data extraction.
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Question 10: What is the expected timeline for completing the project?
Answer 10: The project is expected to take one and a half to two years. This timeline should be
communicated to leadership to secure necessary funding and support.
Question 11: What ongoing support does MPOG provide?
Answer 11: MPOG provides ongoing support through its Technical Support team, Clinical
Informatics Specialists, and Quality Improvement Specialists, who assist with onboarding,
technical setup, and troubleshooting.
Question 12: What was the overall experience of the team with MPOG's requirements and
processes?
Answer 12: The team found the process detailed but manageable with appropriate support. Early
guidance, continued collaboration with IT, and a structured approach helped the team complete
the work successfully.
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Appendix C – MPOG Technical Guides
Technical Guides
• MPOG Import Manager File Specification
• MPOG Import Manager Playbook
• MPOG App Suite User Guides
• MPOG App Suite Frequently Asked Questions
Supplemental Extract Specifications
• Patient Attributes File Specification
• Microbiology File Specification
Additional Technical Tools
• Available on our website at https://mpog.org/downloads/
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Glossary
Administration Type – The mapping type used for medications, fluids, blood products, and other intake
or output data.
ADT – Admission, Discharge, and Transfer data used to show changes in a patient’s admission status.
AIMS – Anesthesia Information Management System—the EHR used to document anesthesia cases.
AIMS Variable – A data element from your site’s EHR, defined in the extract. Also called a variable. This
is the term in “EHR Language.”
Blinded Record Index (BRI) – The former name for Privacy Preserving Record Linkage (PPRL), a method
that uses one-way hashed identifiers to link patient records across data sources without sharing
protected health information.
Case Viewer – The MPOG application used to review data for individual cases in a standardized format.
Data Diagnostics – The MPOG application used to identify potential extraction, transformation, and
mapping issues through data summaries and visualizations.
EHR – Electronic Health Record; the source system used to document patient care and provide data for
the MPOG extract.
Entered Time – When the procedure, event, or care was documented.
Extract – The process or files used to retrieve data from the source EHR or another system for import
into MPOG.
Import Manager – The MPOG application and process used to import extracted files into the site’s local
MPOG database.
Mapping Type – The general mapping category, which can be filtered to subcategories.
Module – A category of related data within the MPOG data structure, such as Cases, Labs, Patients,
PeriopAdministrations, or PeriopObservations.
MPOG App Suite – The collection of MPOG applications used to review, map, validate, clean, and
transfer site data.
MPOG Concept – A standardized term created by MPOG so sites using different EHRs can share
common data elements. This is the term in “MPOG Language.”
MPOG Concept ID – The unique numeric identifier assigned to an MPOG concept.
Observed Time – When the procedure, event, or care was performed. MPOG uses Observed Time for
most phenotypes, quality measures, and research.
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Observation Detail Type – The mapping type used for details associated with an observation or event,
such as airway device size or block technique.
Observation Type – The mapping type generally used for physiologic data, events, notes, outcomes, and
other clinical observations.
Organization – Your institutional name. Multi-site institutions should map under All Assigned
Organizations (Merged).
Phenotype – A defined set of data criteria used to identify a clinical condition, event, or patient
population in MPOG data.
PHI – Protected Health Information; individually identifiable health information that must be protected
and removed before data is transferred to MPOG Central.
Privacy Preserving Record Linkage (PPRL) – Formerly called the Blinded Record Index (BRI), a method
that uses one-way hashed identifiers to link patient records across data sources without sharing
protected health information.
Value – The text or numeric description related to a variable.
Variable ID / Variable Name – The ID and name that come from the extract and reflect your EHR
documentation. Each variable has a distinct ID and name.
Variable Mapping – The process of linking a site’s EHR variables to standardized MPOG concepts.