Information on a person who participates or is expected to participate in the care of a patient.

Data Element
Provider NPI
Submitted By: Robert C Dieterle / On behalf of the Da Vinci Project
Data Element Information
Use Case Description(s)
Use Case Description The collection and exchange of specific provider identifiers helps to ensure that the appropriate provider is attributed to clinical and administrative information that is collected and exchange to support coordinated patient care. In particular, the use of NPI avoids the confusion that exists with basic provider demographics where various name changes, similarity of names, and abbreviations lead to error in associating a clinical or administrative activity with the appropriate responsible provider .

In the case of DEA numbers is even more important to exchange the DEA Number with any mediation order for a controlled substance. This has become especially critical with the significant impact of Opioid addiction on a broad segment of the population.
Estimate the breadth of applicability of the use case(s) for this data element Level 2 – all licensed providers in the NPPES data base (>1,000,000) and all providers that can prescribe controlled substances (>85,000). It impacts all hospitals (>7,000), payers (>1,800), Pharmacies (>88,000), Laboratories (>260,000) and patients (> 350 Million)
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) NPPES assigns a unique number to each registered provider
DEA assigns a number to each requesting and qualified healthcare professional.
Additional Specifications NPI information is currently defined in both the C-CDA 2.1 and in the US Core Profiles 3.1.1 for FHIR R 4.0.1. The representation of Provider NPI in FHIR is in the Practitioner resource in the Practitioner.identifier element. A separate occurrence of the same element can be used to exchange the DEA number.
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts The NPI is required in any transaction between a provider and payer for payment or authorization. NPI is usually included in C-CDAs to indicate the provider responsible for specific observations or actions. NPI is required to order any medication and for most healthcare services or devices. DEA number is always required to order controlled substances.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts HL7 US Core 3.1.1 Profile on Practitioner
NCPDP Script Standard – exchanged for all medication orders and orders for controlled substances
ASC X12N transactions for claims and prior authorization among others
Level 2 – these elements are exchange millions of times a day as part of both clinical and administrative transactions
Numerous summaries of exchanges are available to support the volume of transaction including volume summaries from CAQH, CMS, ONC, AMA, WEDI, NCPDP, and Direct Trust, just to mention a few.

Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) May be restrictions on the exchange of DEA numbers
Privacy and Security Concerns Since the NPI and DEA number are specific to the provider and are associated with specific clinical transactions, there may be provider sensitivity to their exchange
Estimate of Overall Burden Little or no impact – this data is already captured in EHRs and Payer Systems and should be available for inclusion in the appropriate exchanges.
Other Implementation Challenges None at this time
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This data element represents a specialization or a subset of the USCDI v4 data element Care Team Member(s) Identifier.

Comment

Submitted by nedragarrett_CDC on

CDC's comment on behalf of CSTE for USCDI v5

CSTE agrees with CDC's recommendation for this data element. Often provider name and contact information are missing from reports received by public health. Depending on the urgency of a reported case it can be critical for public health staff to be able to quickly identify and reach the medical provider to investigate a case or outbreak of disease, particularly infectious diseases, and having an identifier such as NPI can be extremely helpful in achieving this during emergencies. 

Submitted by nedragarrett_CDC on

CDC's comment on behalf of CSTE

CSTE is supportive of Care Team Provider NPI being included in v3. This information assists public health departments in identifying who to contact at the healthcare facilities for further information about the patient during case and outbreak investigations (receiving care provider name is often insufficient given common names and missing or erroneous contact information for the provider). 

Submitted by nedragarrett_CDC on

Unified Comment from CDC

  • General Comment: Many Chiropractors, Dentists, Nurses, Pharmacists, Physical Therapists, Physicians, Psychologists, and other providers who are party to HIPAA standard transactions, must use the NPI in place of other provider identifiers. (see: https://nppes.cms.hhs.gov/webhelp/nppeshelp/HEALTH%20INFORMATION%20EXCHANGE.html) The Provider NPI is widely captured, used, and exchanged by EHR and HIT systems.
     
  • Additional Use Cases: The MedMorph Public Health Use Cases of Health Care Surveys and Cancer Registry Reporting as well as the electronic case reporting (eCR) use case use Provider NPI as an important provider identifier for internal registry and external to registry linking and provider identification or matching purposes. Links to Use Case Project Pages: https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html, https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm, https://www.cdc.gov/cancer/npcr/, https://www.cdc.gov/ecr/index.html
     
  • Additional Applicable Standards: HL7 CDA ® Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1, DSTU Release 1.1 – US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=398.
     
  • HL7 CDA® R2 Implementation Guide: National Health Care Surveys (NHCS), R1 STU Release 3 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=385
     
  • HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm:http://hl7.org/fhir/us/ecr/STU1/Electronic_Initial_Case_Report_(eICR)_Transaction_and_Profiles.html
     
  • HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 - US Realm - the Electronic Initial Case Report (eICR): https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436
     
  • CSTE supports inclusion of this measure into USCDI v3

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