Represents a date/time related to an encounter (e.g., scheduled appointment time, check in time, start and stop times).
Submitted By: Joel Andress
/ Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Use Case Description(s)
Use Case Description
Encounter information is used extensively by hospitals, clinicians and providers submitting data for quality measurement. This patient level encounter information provides context for when, why and what type of healthcare encounters occurred which may have led to conditions diagnosed, procedures performed, or medications prescribed. It is used in quality measurement to define a population for measurement based on time of encounter occurrence, and encounter reason, or the location within a hospital an encounter occurred.
It is also critical context for clinicians interpreting transferred information. For example, contextualizing an eGFR measure during an acute care hospitalization excludes it from use in categorizing a patient’s stage of chronic kidney disease. For quality assessment, the context of encounters is the cornerstone of attribution and accountability for performance.
Estimate the breadth of applicability of the use case(s) for this data element
More than 4,000 hospitals and 1 million providers are currently capturing, accessing and exchanging this encounter level information. This information is currently electronically submitted by providers and hospitals, or their Health IT firms/EHR vendors, to CMS for quality measurement.
Data exchange of encounter information is also critical for clinical care. Clinicians need to be aware of recent healthcare encounters, including the type of encounter, the reason for the visit, how recent that encounter was (date/time) and discharge disposition and diagnosis in order to provide relevant and quality care for the patient thereafter.
Currently, this type of encounter information is exchanged as part of care coordination and admission/discharge/transfer notifications as part of ONC interoperability standards.
Estimate the breadth of applicability of the use case(s) for this data element
All healthcare providers using certified electronic health record technology (CEHRT) should be capturing, accessing, using and exchanging these encounter data elements.
Actively monitoring diseases, making decisions about public health threats, identifying trends in healthcare services utilization and other public health matters depend on accessible and accurate data. EHRs are a data source that can provide timely and relevant data beyond its use by health care providers. EHR data, if made more available for public health professionals and researchers, can lead to more rapid disease detection, tracking, and treatment and innovation in healthcare delivery.
A patient's encounter with a provider of medical services, ranging from an ambulatory office visit with the patient's primary care provider, to a sudden, acute injury necessitating a trip to an Emergency Department to an admission to and subsequent discharge from a hospital for surgery is a fundamental organizing principle across the healthcare industry. The encounter class of data elements is widely used in EHRs and other systems for clinical care, payment purposes and operational efficiency. Beginning with the encounter status, often used as a trigger for clinical workflow, through classifying, numerically identifying and assigning a date and time to the encounter, to identifying the patient and provider subjects of the encounter as well as their roles form the structure of the encounter these encounter elements have varied clinical and administrative uses. The chief complaint, reason for visit and encounter diagnoses capture the richness of the encounter while the expected source of encounter payment and encounter discharge disposition provide information for follow up and payment. The majority of the candidate encounter data elements here are either mandatory or must support data elements of the US CORE Encounter Profile or Shall or Should data elements in many CDA use cases.
The Making EHR Data More Available for Research and Public Health (MedMorph) project's goal is to create a reliable, scalable, and interoperable method to get electronic health record data for multiple public health and research scenarios (use cases). MedMorph has identified Cancer Registry Reporting, Healthcare Surveys, Electronic Initial Case Reporting (eCR), Hepatitis C Reporting, Birth Reporting and Research (PCORNet) use cases that support the adoption of these encounter data elements. These specific use cases are described in more depth on their respective web pages.
Estimate the breadth of applicability of the use case(s) for this data element
Estimate the number of stakeholders who would capture, access, use or exchange this data element or data class: All 50 states participate in one or more of the MedMorph public health and research use cases that exchange these encounter data elements. Up to 14 territorial or city jurisdictions also participate in one of these public health use cases and use these data elements.
All hospitals and physicians who diagnose or treat cancer are required to provide encounter information to state cancer registries.
Approximately 620,000 physicians in the US are active and have at least some component of ambulatory practice and thus are annually eligible to sampling and recruitment into the National Ambulatory Medical Care Survey (NAMCS), which samples from between 3,500 to 20,000 of these physicians annually. Presently each sampled physician submits one weeks' worth of patient encounters to NAMCS. Approximately 600 hospitals are in the National Hospital Care Survey (NHCS). 1/3 of that number are either in, or actively being recruited into, the EHR data submission mode for NHCS. NHCS is already receiving electronic CDA documents. When they reach their target of 200 hospitals submitting by this mode annually they will be receiving >1.2 million documents and sets including multiple sets of medication data annually.
Related to birth reporting, every year there are approximately 3.7 million births in the United States. Consumption of this data is widespread. Every jurisdiction in the country captures birth certification information and immunization administration. Most also capture birth defects and fetal deaths. Healthcare systems that provide care for expectant mothers should be collecting this data.
There were approximately 1,000,000 practicing physicians (as of 2020), approximately 120,000 certified physician assistants (as of 2019) and 290,000 licensed nurse practitioners (as of 2019). Most of these licensed clinicians interact with one of these public health use cases intermittently, annually. As of 2018 AHA reported 6,146 hospitals in the US experiencing 36,353,946 admissions. Almost all of those hospitals and many of the admissions interact with one or more of the public health and or research use cases. The vast majority of these exchanges include most or at least some of the encounter data elements contained in this submission.
Healthcare Aims
Improving patient experience of care (quality and/or satisfaction)
Improving the health of populations
Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)
Encounter type/occurrence:
SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307)
HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087)
CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001)
HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html
Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis:
SNOMED CT
ICD-10-CM
Discharge Disposition:
DischargeDisposition
Code System http://terminology.hl7.org/CodeSystem/discharge-disposition
This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts
Encounter data is routinely captured in EHR systems used by hospitals, providers, and other healthcare stakeholders. Encounter-based EHR data is submitted by providers to CMS via QRDA I and III files and other data architectures from hospitals, providers, health IT firms, and vendors for eCQM public reporting in CMS IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of patient and encounter based data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes encounter details including admission and discharge date/times or office visit date/times to determine which patients are included in the measurement periods, type of encounter, and encounter diagnoses/primary reason, discharge dispositions, and encounter location details to determine the population of interest, or measure exclusions.
Widely available in EHR systems: https://fhir.cerner.com/millennium/r4/encounters/encounter/ https://open.epic.com/Interface/FHIR https://mydata.athenahealth.com/fhirapidoc
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
Encounter data for quality measurement is electronically exchanged from organization’s EHR systems to CMS for reporting and payment quality measurement programs, via QRDA files and other data architectures. These encounter data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly electronically captured and exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
Encounter data has also been electronically exchanges with external organizations via C-CDA, as part of ONC’s requirements and a part of data exchange for the continuum of care to notify of admissions, discharges, and transfers of care.
Restrictions on Standardization (e.g. proprietary code)
No challenges anticipated. This data is available in standard terminology that can be publicly access via the VSAC and HL7.
Restrictions on Use (e.g. licensing, user fees)
We are not aware of any restrictions.
Privacy and Security Concerns
This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden
Encounter data is regularly captured by a broad range of healthcare providers, and should not cause burden to implement. This data is already regularly exchanged and available in standardized fields and terminology. It is also required by the US Core Capability Statement and therefore will be stood up by those stakeholders complying with the ONC requirement for the Standardized FHIR API for patient and population services.
Add an element or attribute that can be associated with each instance of a date/time to indicate the semantic meaning of that date/time. In emergency medical services (ambulance calls), many date/time values are collected throughout an encounter, such as notification, en route, arrived on scene, arrived at patient, left scene, arrived at destination, back in service, etc.).
This comment is submitted on behalf of the National Emergency Medical Services Information System (NEMSIS) Technical Assistance Center.
We would need to consider capturing this variable in order to support the following 6 domains related to Paul Coverdell National Acute Stroke Program/American Hospital Association’s (AHA) Get With The Guidelines (GTWG). • The goal is to reduce gaps in stroke care across the continuum of care in states with high burden populations. The information captured from stroke patients and those who encounter mobility related issues and are at risk of multiple hospitalizations due to post-discharge complications can help in reducing the gaps in care and to plan quality improvement efforts. # Domain # of Variables Variable Details Required or Optional 1 Hospital Discharge Date 1 1. date of hospital discharge Required 2 Hospital Admission Date 1 1. hospital admission date Optional 3 Follow-up 4 1. if follow-up phone call conducted, date 2. if in home follow up conducted, date 3. if chart review conducted, date 4. if follow-up conducted at a health facility, date Required 4 ED Visits 2 1. if patient seen in the ED since discharge, date information about ED visits gathered if before 30 days 2. if yes, Date of first ED visit Optional 5 Follow Up Appointment 1 1. date of first follow up appointment Optional 6 Readmissions 1 1. if readmitted, date of first readmission Optional Use-Case Justification: The most challenging part is capturing the information post-hospital discharge for acute stroke patients. A lot of the pre-hospital care is captured through National Emergency Medical Services Information System (NEMSIS), a national database that stores EMS data from the U.S. States and Territories). The follow-up elements proposed above have been developed as a part of the Paul Coverdell National Acute Stroke Program (link provided below) and captured within EHR for submission into American Heart Association’s (AHA) Get With The Guidelines (GTWG) module. The ability to extract the follow-up encounter related dates would help with the identification of gaps in post-hospital discharge date for stroke patients and plan strategies for Quality Improvement efforts. https://www.cdc.gov/dhdsp/programs/stroke_registry.htm This field is for general comments on this specific data element. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC
USCDI_Version_2_Draft_Template for Comments_DHDSP_vFinal_04.14.2021.docx
For encounter time, CMS's submission intended to recommend including an encounter date/time, or the date/time the encounter began (i.e. admission date/time for inpatient admissions, date/time for office visit) and date/time when the encounter ended (i.e. hospital encounter discharge date/time). We agree there are many date/times that could be defined, and that are important for different use cases.
We recommend that ONC clarify “encounter” and “encounter time” and explain whether it applies to a daily visit (day/time/start and stop time) or an episode’s admission and discharge, which is comprised of numerous daily visits. In a facility setting, it is important to recognize that there can be many parallel encounters; for instance, numerous health care professionals conduct visits with a patient who is residing in long-term care facility; a patient may be admitted for 100 days, during which time a record is created each day (physical therapist treats in the morning, physical therapist assistant treats in the afternoon). Thus, is an encounter time representative of the patient’s entire stay in the skilled nursing facility, or each daily individual visit (which may be comprised of numerous visits by different health care professionals)? In the emergency department, a patient may be evaluated and treated by different clinicians, including a physical therapist. Thus, is encounter time admission and discharge from the hospital/emergency department, or the beginning and end of each clinician’s visit, and/or the beginning and end of a procedure? Other questions that must be resolved in the final USCDI:
Is encounter date/time representative of the date and time of the encounter with the patient, or the date and time that the documentation is completed? Most clinicians do not collect start and stop times for an encounter. Moreover, is date and time intended to be reflected via a timestamp? Also, we question which timestamp would travel with the documentation, as a clinician may see a patient at one time during the day and complete their documentation at another time that day. Should the encounter time be the time the treatment occurred or the time the documentation entry occurred or both or neither?
Does encounter time encompass duration? Requiring duration to be reported can create challenges between “duration” for a CPT code vs. duration of the entire session. In addition, the actual duration of the visit is not currently collected in all locations or by all practitioners. Finally, while the documentation itself may or may not include the duration, although the billing should reflect the time of each intervention and match the documentation.
Is encounter time intended to reflect when the treating or evaluating clinician begins to provide skilled care for the patient, or is it more broadly the time of the scheduled appointment?
Is it intended to capture time involved in direct one on one patient care or the overall visit? For instance, in a physical therapy office visit, frequently both the physical therapist and physical therapist assistant will treat the patient (at separate times).
Would the start time of the physical therapist be captured, as well as the start time of the physical therapist assistant?
Additional clarification is necessary.
CMS's submission of the encounter time data element was intended to recommend inclusion of a patient encounter start and stop date/time. This would encompass the time the encounter began (i.e. admission date/time for inpatient admissions, date/time for office visit) and when appropriate (i.e. hospital encounters) a discharge date/time, or when the encounter ended. We did not intend to recommend start/stop times for daily visits/clinician treatment sessions that occur during an encounter.
Is this intended to also capture duration or classification (long, short, regular, etc) of a visit for an office visit? Some of the content above make me think it might be. Is it meant to be the scheduled start time or the actual start time or the patient check-in time? There are comments about encounter diagnosis and encounter type above under applicable standards - is that intentional?
CMS submitted several distinct encounter data elements for consideration in USCDI, including encounter time, encounter diagnosis, and encounter type. For encounter time, our submission intended to recommend including an encounter date/time, or the time the encounter began (i.e. admission date/time for inpatient admissions, date/time for office visit) and when appropriate (i.e. hospital encounters) a discharge date/time, or date/time when the encounter ended.
• We would need to consider capturing this variable in order to support the following 6 domains related to Paul Coverdell National Acute Stroke Program/American Hospital Association’s (AHA) Get With The Guidelines (GTWG).
• The goal is to reduce gaps in stroke care across the continuum of care in states with high burden populations. The information captured from stroke patients and those who encounter mobility related issues and are at risk of multiple hospitalizations due to post-discharge complications can help in reducing the gaps in care and to plan quality improvement efforts.
# Domain # of Variables Variable Details Required or
Optional
1 Hospital Discharge Date 1 1. date of hospital discharge Required
2 Hospital Admission Date 1 1. hospital admission date Optional
3 Follow-up 4 1. if follow-up phone call conducted, date
2. if in home follow up conducted, date
3. if chart review conducted, date
4. if follow-up conducted at a health facility, date Required
4 ED Visits 2 1. if patient seen in the ED since discharge, date information about ED visits gathered if before 30 days
2. if yes, Date of first ED visit Optional
5 Follow Up Appointment 1 1. date of first follow up appointment Optional
6 Readmissions 1 1. if readmitted, date of first readmission Optional
Use-Case Justification: The most challenging part is capturing the information post-hospital discharge for acute stroke patients. A lot of the pre-hospital care is captured through National Emergency Medical Services Information System (NEMSIS), a national database that stores EMS data from the U.S. States and Territories). The follow-up elements proposed above have been developed as a part of the Paul Coverdell National Acute Stroke Program (link provided below) and captured within EHR for submission into American Heart Association’s (AHA) Get With The Guidelines (GTWG) module. The ability to extract the follow-up encounter related dates would help with the identification of gaps in post-hospital discharge date for stroke patients and plan strategies for Quality Improvement efforts.
https://www.cdc.gov/dhdsp/programs/stroke_registry.htm
This field is for general comments on this specific data element. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC
We recommend that ONC clarify “encounter” and “encounter time” and explain whether it applies to a daily visit (day/time/start and stop time) or an episode’s admission and discharge, which is comprised of numerous daily visits.
In a facility setting, it is important to recognize that there can be many parallel encounters; for instance, numerous health care professionals conduct visits with a patient who is residing in long-term care facility; a patient may be admitted for 100 days, during which time a record is created each day (physical therapist treats in the morning, physical therapist assistant treats in the afternoon). Thus, is an encounter time representative of the patient’s entire stay in the skilled nursing facility, or each daily individual visit (which may be comprised of numerous visits by different health care professionals)?
In the emergency department, a patient may be evaluated and treated by different clinicians, including a physical therapist. Thus, is encounter time admission and discharge from the hospital/emergency department, or the beginning and end of each clinician’s visit, and/or the beginning and end of a procedure?
Other questions that must be resolved in the final USCDI:
Is encounter date/time representative of the date and time of the encounter with the patient, or the date and time that the documentation is completed? Most clinicians do not collect start and stop times for an encounter. Moreover, is date and time intended to be reflected via a timestamp? Also, we question which timestamp would travel with the documentation, as a clinician may see a patient at one time during the day and complete their documentation at another time that day. Should the encounter time be the time the treatment occurred or the time the documentation entry occurred or both or neither?
Does encounter time encompass duration? Requiring duration to be reported can create challenges between “duration” for a CPT code vs. duration of the entire session. In addition, the actual duration of the visit is not currently collected in all locations or by all practitioners. Finally, while the documentation itself may or may not include the duration, although the billing should reflect the time of each intervention and match the documentation.
Is encounter time intended to reflect when the treating or evaluating clinician begins to provide skilled care for the patient, or is it more broadly the time of the scheduled appointment?
Is it intended to capture time involved in direct one on one patient care or the overall visit? For instance, in a physical therapy office visit, frequently both the physical therapist and physical therapist assistant will treat the patient (at separate times).
Would the start time of the physical therapist be captured, as well as the start time of the physical therapist assistant?
How many encounters can you put on the same form for the same mental illness for different times throughout the same day for accurate billing by the same provider?
Is this intended to also capture duration or classification (long, short, regular, etc) of a visit for an office visit? Some of the content above make me think it might be.
Is it meant to be the scheduled start time or the actual start time or the patient check-in time?
There are comments about encounter diagnosis and encounter type above under applicable standards - is that intentional?
The MedMorph Project fully supports the addition of this element for USCDI v2. The encounter period is a necessary element for the MedMorph Healthcare Survey use case.
Submitted by joshualegler on
Encounter Time Type
Add an element or attribute that can be associated with each instance of a date/time to indicate the semantic meaning of that date/time. In emergency medical services (ambulance calls), many date/time values are collected throughout an encounter, such as notification, en route, arrived on scene, arrived at patient, left scene, arrived at destination, back in service, etc.).
This comment is submitted on behalf of the National Emergency Medical Services Information System (NEMSIS) Technical Assistance Center.