Medications

CSTE Comment - v5

Medication data is critical for exchange with public health and is included in eCR standards. It is especially important for STI programs, HIV and TB surveillance as well as for public health response and surveillance for antimicrobial resistant pathogen infections. CSTE also strongly agrees that the ability to exchange data on prescribing of opioid medications in particular is of great importance to public health programs which aim to reduce opioid overdoses and deaths.

CDC's Comment for draft USCDI v5

CDC-CMS Joint Priority Data Element. 

See letter here (submitted on 1/29/2024): https://www.healthit.gov/isa/sites/isa/files/2024-02/FINAL_CDC%20and%20CMS-CCSQ%20Joint%20USCDI%20v5%20submission%20letter_012924.pdf

CDC and CMS-CCSQ Joint Support for Discharge Medications

Thank you for opportunity to comment on this data element. The Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) emphasize the importance of patient safety being reflected in the USCDI standards. As an integral aspect of patient safety, medication management is critical to patient care and coordination between providers, and related quality and public health enterprises. Medication administration, specifically, is a critical concept for CMS and CDC programs that support quality improvement and public health surveillance. We continue to emphasize the need for greater specificity in the USCDI Medications data class. The medications data class in USCDI is currently inadequate to support patient safety, quality improvement, or public health. The medication data elements do not differentiate among medications that are active, ordered, and administered/prescribed to the patient. Given these complexities, more clarity and structure are necessary in this data class to accurately evaluate and provide clinical care and promote patient safety. CMS and CDC strongly recommend the Discharge Medications (Level 0) in the Medications data class be added to USCDI.

CDC's comment on behalf of CSTE for USCDI v5

• CSTE agrees with CDC.
• Medication data is critical for exchange with public health and is included in eCR standards. It is especially important for STI programs, HIV and TB surveillance as well as for public health response and surveillance for antimicrobial resistant pathogen infections. CSTE also strongly agrees that the ability to exchange data on prescribing of opioid medications in particular is of great importance to public health programs which aim to reduce opioid overdoses and deaths.

CDC's Consolidated Comment for USCDI v5

** ADD THIS USE CASE TO SUBMISSION ** 

• "Medication Opioids": Unintentional injuries are the leading cause of death for Americans aged 1–44 years. The leading cause of death for unintentional injury is poisoning, specifically drug overdose. Overdose deaths continue to climb each year and accelerated during the COVID-19 pandemic. The majority of national overdose deaths involve opioids. Many patients receive their first exposure to opioids following surgery, and dentists are the leading prescriber of opioids among adolescents aged 10-19 and second-leading prescriber among young adults aged 20–29. In 2004, an estimated 3.5 million patients had wisdom teeth extracted. Filled opioid prescriptions after wisdom tooth extraction is associated with higher odds of persistent opioid use among opioid-naïve patients. Better understanding prescribing habits can help identify risk factors and particularly vulnerable populations.
• "Medications Antibiotics": More than 2.8 million antimicrobial-resistant infections occur in the United States each year, and more than 35,000 people die as a result. When Clostridioides difficile is added to these, the US toll exceeds 3 million infections and 48,000 deaths. The threat of antibiotic resistance undermines progress in health care, food production, and life expectancy. Addressing this threat requires preventing infections in the first place, slowing the development of resistance through better antibiotic use, and stopping the spread of resistance when it develops. Research shows that dentists overuse antibiotics, particularly for patients who are underinsured. Dentists prescribe 10% of all outpatient antibiotics, although there is significant geographical variability. Better understanding prescribing practices, knowledge, and beliefs can aid in the development of meaningful antimicrobial stewardship efforts addressing case selection and areas of practice.

NACCHO Supports CDC's Comment.

CMS-CCSQ/CDC Joint USCDIv4 Priority – Discharge Medications

Management of medications is critical to patient care and coordination between providers, as well as related quality and public health enterprises. The current concept of medications in USCDI does not differentiate among medications that are active, ordered, and actually administered/prescribed to the patient. Given these complexities, more clarity and structure are necessary in this data class to accurately evaluate and provide clinical care.

• We recommend the following elements be added regarding medications:
  • Medications Prescribed
  • Medications Administration/Medication Administered Code
  • Discharge Medications
  • Medication Administration Route
  • Medication Administration Dose
  • Medication Administration Date and Time

We continue to urge adding more specificity to the USCDI Medications Data Class. These medication data elements are necessary for understanding adverse drug events, opioid use and misuse, and medication access.

The highlighted additional data elements serve the ONC USCDI v4 stated priorities related to mitigating health inequities and disparities, addressing needs of underserved populations, and addressing public health reporting needs.

Please Include Discharge Medications in USCDI v4

Vizient recommends adding the Discharge Medications data element to USCDI v4 as this element distinguishes which medications were prescribed for a patient to start/continue from the point of discharge and would minimize confusion with medications prescribed as an inpatient.

Additional comment from CDC for USCDI v4

• Additional Use Cases from Department of Oral Health

1. Medication - Opioid Overdose: Unintentional injuries are the leading cause of death for Americans aged 1–44 years. The leading cause of death for unintentional injury is poisoning, specifically drug overdose. Overdose deaths continue to climb each year and accelerated during the COVID-19 pandemic. The majority of national overdose deaths involve opioids. Many patients receive their first exposure to opioids following surgery, and dentists are the leading prescriber of opioids among adolescents aged 10­­–19 and second-leading prescriber among young adults aged 20–29. In 2004, an estimated 3.5 million patients had wisdom teeth extracted. Filled opioid prescriptions after wisdom tooth extraction is associated with higher odds of persistent opioid use among opioid-naïve patients. Better understanding prescribing habits can help identify risk factors and particularly vulnerable populations.
2. Medication - Antibiotic Overuse: More than 2.8 million antimicrobial-resistant infections occur in the United States each year, and more than 35,000 people die as a result. When Clostridioides difficile is added to these, the US toll exceeds 3 million infections and 48,000 deaths. The threat of antibiotic resistance undermines progress in health care, food production, and life expectancy. Addressing this threat requires preventing infections in the first place, slowing the development of resistance through better antibiotic use, and stopping the spread of resistance when it develops.

   Research shows that dentists overuse antibiotics, particularly for patients who are underinsured. Dentists prescribe 10% of all outpatient antibiotics, although there is significant geographical variability. Better understanding prescribing practices, knowledge, and beliefs can aid in the development of meaningful antimicrobial stewardship efforts addressing case selection and areas of practice.

CDC's Consolidated Comment for USCDI v4

• This data element is CDC-CMS joint priority for V4 

 CDC and CMS urge adding more specificity to the USCDI Medications Data Class as interoperability of medication information and management of medications is critical to patient care and coordination between providers, as well as related quality and public health enterprises—we continue to support the concept of a USCDI Task Force to appropriately specify and advance this important data class. The highlighted additional data elements serve the ONC USCDI v4 stated priorities related to mitigating health inequities and disparities, addressing needs of underserved populations, and addressing public health reporting needs. Specifically, these medication data elements are necessary for understanding adverse drug events, opioid use and misuse, and medication access.  The current concept of medications in USCDI does not differentiate among medications that are active, ordered, and administered/dispensed to the patient. Given these complexities, more clarity and structure are necessary in this data class to accurately evaluate and provide clinical care. These detailed medication data were also previously identified as a joint CMS-CDC priority area as they are used extensively in quality measurement and public health—for example, to monitor and respond to antibiotic prescribing patterns that facilitate the emergence of drug-resistant pathogens, but also exposes patients to needless risk for adverse effects. re. They are also and are routinely exchanged when prior authorization is required 

• Additional use cases:  Patient safety quality measurement and public health surveillance via NHSN  AUR surveillance via NHSN

1. Comments from NACCHO: NACCHO supports including the data element discharge medications
2. Comments from CSTE: CSTE agrees with CDC. Medication data is critical for exchange with public health and is included in eCR standards. It is especially important for STI programs, HIV and TB surveillance as well as for public health response and surveillance for antimicrobial resistant pathogen infections.

CMS-CCSQ/CDC Joint USCDIv4 Priority - Discharge Medications

CMS urges adding more specificity to the USCDI Medications Data Class as interoperability of medication information and management of medications is critical to patient care and coordination between providers, as well as related quality and public health enterprises—we continue to support the concept of a USCDI Task Force to appropriately specify and advance this important data class. The highlighted additional data elements serve the ONC USCDI v4 stated priorities related to mitigating health inequities and disparities, addressing needs of underserved populations, and addressing public health reporting needs. Specifically, these medication data elements are necessary for understanding adverse drug events, opioid use and misuse, and medication access.

The current concept of medications in USCDI does not differentiate among medications that are active, ordered, and actually administered/dispensed to the patient. Given these complexities, more clarity and structure are necessary in this data class to accurately evaluate and provide clinical care. These detailed medication data were also previously identified as a joint CMS-CDC priority area as they are used extensively in quality measurement and public health —for example, to monitor and respond to antibiotic prescribing patterns that facilitate the emergence of drug-resistant pathogens, but also exposes patients to needless risk for adverse effects. They are also routinely exchanged when prior authorization is required.

Maturity: These elements are classified as Level 2 by ONC and continues to have strong standardization and be in wide use.

• Current standards:
  • In FHIR US Core, there is a distinction between "Medication" and "Medication Request”; base FHIR and FHIR Quality Improvement (QI) Core IG includes "Medication Administration" and “Medication Request” profiles.
  • Within Medication Request, the ‘category’ is used to define discharge medications.
• Current uses, exchange, and use cases: Medication data are routinely captured in electronic health record (EHR) systems used by hospitals, providers, and other healthcare stakeholders, including pharmacies, and are routinely exchanged across providers and payers. Medication data are used extensively in CMS quality measurement and public health for surveilling national trends. Additionally, when prior authorization is necessary for a medication, details related to the medication (e.g., why the medication is given, the quantity needed) are exchanged to support the approval process. As noted in the ISWG recommendations report for USCDI v3, many medication data elements are already required for Health Information Technology (IT) Certification via other standards (National Council for Prescription Drug Programs [NCPDP] SCRIPT, Consolidated Clinical Document Architecture [C-CDA]) and are therefore already routinely exchanged, posing little additional burden by adding them to the USCDI.