| Submitted By: Adam Bazer, MPD
/ Integrating the Healthcare Enterprise USA (IHE USA)
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| Data Element Information |
| Use Case Description(s) |
| Use Case Description |
Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to 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 new innovations and more rapid disease detection.
Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to 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 new innovations and more rapid disease detection.
Capturing birth order for multiple births is important for public health reporting and helps with identfying if a newborn or fetal death has potentially greater susceptibility to a unfavorable perinatal outcome. Being part of patient demographics ties directly to the patient and not the details of the delivery for either the mother or newborn.
Patient demographics such as patient birth place (City, Town, County Or Location Of Delivery), and patient country of birth are patient demographics utilized by multiple public health use cases to help assess characteristics within patient populations.
The public health use case(s) that support the adoption of these added elements are part of the Making EHR Data More Available for Research and Public Health (MedMorph) Reference Architecture. MedMorph has identified Cancer Reporting, Healthcare Surveys, Hepatitis C Reporting, electronic Initial Case Reporting (eICR), Multiple Chronic Conditions (MCC) eCare Plan, Message Mapping Guide (MMG) for COVID 19, PCORnet, Birth and Birth Defect Reporting use cases that support the adoption of these data elements. The goal of the MedMorph project is to develop and pilot a scalable and extensible standards-based reference architecture. This reference architecture will enable clinical data exchange with EHR systems and public health systems, specialized registries, national health care survey systems, and research information systems for multiple conditions. |
| Estimate the breadth of applicability of the use case(s) for this data element
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All 50 states participate in one or more of the public health surveillance use cases that exchange this data element.
All hospitals and physicians who diagnose or treat cancer are required to provide cancer related information to state cancer registries. Vital records reporting such as birth, fetal death and death are also required to be reported by each state. Every year there are approximately 2.8 million deaths and 3.7 million births in the United States.
Approximately 420,000 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.
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 at least half of the admissions interact with one or more of the public health use cases.
Additionally, public health reporting use cases are part of the of the Center for Medicare and Medicaid (CMS) Meaningful Use/Promoting Interoperability program adding on to the list of stakeholders under public health registries who capture electronic health information. |
| Link to use case project page |
https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html https://www.cdc.gov/cancer/npcr/ https://www.cdc.gov/hepatitis/hcv/index.htm https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm https://www.cdc.gov/ecr/index.html https://pcornet.org/ |
| Use Case Description |
The MedMorph project is being developed with the goal of generalizability to support many more public health and research use cases. Therefore, other public health and research use cases that use the MedMorph architecture will also benefit from adoption of this data element. |
| Estimate the breadth of applicability of the use case(s) for this data element
|
All 50 states participate in one or more of the public health surveillance use cases that exchange this data element.
All hospitals and physicians who diagnose or treat cancer are required to provide cancer related information to state cancer registries. Vital records reporting such as birth, fetal death and death are also required to be reported by each state. Every year there are approximately 2.8 million deaths and 3.7 million births in the United States.
Approximately 420,000 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.
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 at least half of the admissions interact with one or more of the public health use cases.
Additionally, public health reporting use cases are part of the of the Center for Medicare and Medicaid (CMS) Meaningful Use/Promoting Interoperability program adding on to the list of stakeholders under public health registries who capture electronic health information. |
| Link to use case project page |
https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html https://www.cdc.gov/cancer/npcr/ https://www.cdc.gov/hepatitis/hcv/index.htm https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm https://www.cdc.gov/ecr/index.html https://pcornet.org/ |
| 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
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| Maturity of Use and Technical Specifications for Data Element |
| Applicable Standard(s) |
FHIR patient extension: birthplace
FHIR patient address.period
http://hl7.org/fhir/R4/extension-patient-birthplace.html http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html
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| Additional Specifications |
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. SHALL for the following elements: Patient Address Use Period, Patient Birth Place, Patient Medical Record Number, Patient Social Security Number.
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 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492. SHALL for the following elements: Patient Vital Status. SHOULD for the following elements: Patient Marital Status
HL7 FHIR® US Core Implementation Guide STU3 Release 3.1.1: https://www.hl7.org/fhir/us/core/index.html
HL7 FHIR US Core Patient: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html. MustSupport for the following elements: Patient Medical Record Number, Patient Medicare Number, Patient Social Security Number, Patient Address Use Period
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
IHE Quality, Research and Public Health Birth and Fetal Death Reporting-Enhanced (BFDR-E): https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf
HL7 FHIR Common Data Models Harmonization FHIR Implementation Guide http://hl7.org/fhir/us/cdmh/2019May/ |
| Current Use |
In limited use in production environments |
| Supporting Artifacts |
Level 1 – in limited production (a few) environments, 1 or 2 different EHR/HIT systems
eCase Reporting with The Council of State and Territorial Epidemiologists (CSTE) and The Association of Public Health Laboratories (APHL)
National Health Care Survey Registry - HL7 CDA® R2 Implementation Guide: National Health Care Surveys (NHCS), R1 STU Release 1.2 was never named in a final rule but rather became part of Promoting Interoperability through Certification Companion Guide (CCG) and Test Procedures Updates to the ISA in 2017.
EPIC stork module (obstetrics) for birth reporting.
IHE integration profiles for BFDR (CDA)
EPIC FHIR patient, vitals, obstetric details (DSTU2, DSTU3, R4)
Cerner FHIR patient resource (DSTU2, R4)
Evident FHIR patient resource (DSTU2)
Allscripts FHIR patient resource (DSTU2)
Promoting Interoperability Programs Eligible Hospitals and Critical Access Hospitals are required to, and Merit-based Incentive Payment System (MIPS) participants may optionally, report on any two measures under the Public Health and Clinical Data Exchange objective of these programs. The § 170.315(f)(5) – Transmission to public health agencies – electronic case reporting certification criteria in the 2015 Edition Final Rule and the ONC Cures Act Final Rule, the § 170.315(f)(7) – Transmission to public health agencies – health care surveys, and the § 170.315 (f)(4) – Transmission to Cancer Registries are three such options to meet these measures.
The current standard for § 170.315(f)(5), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7® CDA® R2 Implementation Guide: Public Health Case Report, Release 2: the Electronic Initial Case Report (eICR), Release 1, STU Release 1.1. ONC’s Certified Health IT Product List (CHPL) lists 73 EHR or HIT Module products certified to (f)(5) using this standard.
The current standard for § 170.315(f)(7), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7® CDA® R2 Implementation Guide: National Health Care Surveys (NHCS), R1 DSTU Release 1.2 - US Realm. ONC’s Certified Health IT Product List (CHPL) lists 116 EHR or HIT Module products certified to (f)(5) using this standard.
The current standard for § 170.315 (f)(4), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7 CDA® R2 IG: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, R1, DSTU Release 1.1 - US Realm. ONC’s Certified Health IT Product List (CHPL) lists 288 EHR or HIT Module products certified to (f)(4) using this standard.
These three widely adopted CDA standards have many of the Patient Demographic data elements contained on this form as Shall (required) or Should (best practice to include if available) conformance criteria, which demonstrates the maturity of these commonly exchanged data elements.
https://www.epic.com/software#PatientEngagement https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf https://fhir.epic.com/Specifications?api=932, https://fhir.epic.com/Specifications?api=968, https://fhir.epic.com/Specifications?api
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| Extent of exchange
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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 |
Level 2 – exchanged between 4 or more different EHR/HIT systems. More routinely exchanged between multiple different systems can justify adding to next draft version.
At least 38 state cancer registries have received cancer reports from at least one provider (per internal technical and programmatic documentation) that include these data elements: Patient Medical Record Number, Patient Social Security Number, Patient Marital Status, Patient Address Use Period.
HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 - US Realm - the Electronic Initial Case Report (eICR) is currently implemented in 5,400+ reporting sites nationally and exchanges the following Patient Demographic elements: Patient Identifiers, Patient Marital Status, Patient Gender Identity, Patient Pregnancy Status Observation.
IHE Connectathon integration profiles for BFDR (2013 - 2020) and Cancer reporting (2010 - 2020), death reporting (2019) - tested between electronic death registration vendors (EDRS) and NCHS.
HL7 FHIR Connectathon results (Sept 2020): MedMorph/eCR, birth and fetal death reporting, Integrating cancer reporting
NACCHO 360X Interoperability Demonstrations for Cancer, eCR, Birth and Fetal Death and Death reporting 2020 (CDA and FHIR)
https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 https://connectathon-results.ihe.net/view_result.php?rows=company&columns=actor&title=integration_profi https://connectathon-results.ihe.net/view_result.php?rows=company&columns=act
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| Potential Challenges |
| Restrictions on Standardization (e.g. proprietary code) |
None |
| Restrictions on Use (e.g. licensing, user fees) |
None |
| Privacy and Security Concerns |
Concerns with the use of personally identifying information (PII). However, these data are intended to be a part of the medical record and will be protected as such using proper secure protocols.
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| Estimate of Overall Burden |
For those use cases not currently in production level or who have not tested with vendors may require additional development hours or resources.
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| Other Implementation Challenges |
When using FHIR there may be associated costs with development of tools needed to access specific data. Often these costs may be a limitation for states who need to develop tools to access certain data.
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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
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Criterion #1
Maturity - Current Standards |
Level 2
- Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
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Criterion #2
Maturity - Current Use
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Level 1
- Data element is captured, stored, or accessed in at least one production EHR or HIT module.
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Criterion #3
Maturity - Current Exchange |
Level 1
- Data element is electronically exchanged between two production EHRs or other HIT modules using available interoperability standards.
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Criterion #4
Use Case(s) - Breadth of Applicability |
Level 2
- Use cases apply to most care settings or specialties.
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Submitted by nedragarrett_CDC on
CDC's Consolidated Comment for USCDI v5
NACCHO supports CDC's recommended change.