Data Element
Pregnancy Intention Screening
Description

Screening patient for their desire to become pregnant in the next 12 months in order to determine which reproductive health services may be relevant to offer the patient in that encounter.
Submitted By: Emily Decker / Upstream USA
Data Element Information
Use Case Description(s)
Use Case Description Lack of access to high-quality family planning services is at the root of continued high rates of mistimed and unwanted (i.e., “unintended”) pregnancies among patients in the U.S. Current research shows that at a state level in the U.S., an estimated 26% - 44% of pregnancies are mistimed or unwanted(1). Unintended pregnancy can perpetuate negative health, economic, and social outcomes, and a lack of contraceptive access is a health equity issue that impacts people across socioeconomic levels, but particularly individuals with low socioeconomic status and younger people (2).

One way in which reproductive health advocates are working to address disparities in access to contraceptive care is through initiatives that integrate patient-centered reproductive health services into primary care settings. The CDC and HHS Office of Population Affairs guidelines for quality family planning service provision advocates for routine screening of pregnancy intention and reproductive life plans to provide a full picture of patient health, wellbeing, and services desired (3). Based on patient response to such screening, prenatal care, contraceptive counseling, and other reproductive health services may be offered by the care team. Some pregnancy intention screening tools have been designed and validated specifically for use in primary care settings and can be integrated into primary care workflows and EHR templates (4-6).

There are numerous state- and federal-level contraceptive access programs operating in the U.S (7-10). A growing number of these programs rely on agency-level data from EHRs to analyze the extent to which participating healthcare agencies may be transforming and implementing best-in-class contraceptive care workflows, including documentation rates for pregnancy intention screening. There are standard LOINC and SNOMEDCT codes that can be used to capture and exchange data related to this screening, and these codes have undergone initial testing in FHIR as part of the HHS Office of Population Affairs effort to modernize Title X Family Planning Program annual reporting(11). Pregnancy intention screening is not yet a data element in USCDI, but could be leveraged by multiple stakeholder groups as soon as FHIR becomes widely implemented.

1) Kost, K., Maddow-Zimmet, I., Little, A. Pregnancies and Pregnancy Desires at the State Level: Estimates for 2017 and Trends Since 2012. Guttmacher Institute Report. Accessed 29 September 2021. URL: https://www.guttmacher.org/report/pregnancy-desires-and-pregnancies-state-level-estimates-2017#
2) Iseyemi, A., Zhao, Q., Peipert, J. Socioeconomic Status as a Risk Factor for Unintended Pregnancy in the Contraceptive CHOICE Project. Obstet Gynecol. 2017 Sep; 130(3):609-615. doi: 10.1097/AOG.0000000000002189
3) Gavin, L., Moskosky, S., Carter, M., et al. Providing Quality Family Planning Services Recommendations of the CDC and the U.S. Office of Population Affairs. MMWR 2014;63(no.4). Accessed 27 September 2021. https://opa.hhs.gov/sites/default/files/2020-10/providing-quality-family-planning-services-2014_1.pdf
4) Bellanca, H., Stranger Hunter, M. ONE KEY QUESTION: Preventive reproductive health is part of high quality primary care. Contraception. 2013 May; 88: 3-6. http://dx.doi.org/10.1016/j.contraception.2013.05.003
5) Stulberg, D., Datta, A., White VanGompel, E, et al. One Key Question and the Desire to Avoid Pregnancy Scale: A comparison of two approaches to asking about pregnancy preferences. Contraception. 2020 December; 101: 231-236. https://doi.org/10.1016/j.contraception.2019.12.010
6) https://powertodecide.org/sites/default/files/2020-07/OKQ_Research%20Overview.pdf
7) https://opa.hhs.gov/grant-programs/title-x-service-grants
8) https://upstream.org/
9) https://www.astho.org/Programs/Maternal-and-Child-Health/Increasing-Access-to-Contraception/
10) https://pcainitiative.acog.org/what-we-do/
11) http://build.fhir.org/ig/hspc/ACOG-OPA-IG/output/
Estimate the breadth of applicability of the use case(s) for this data element There are numerous stakeholders that could leverage this data element, if included in USCDI. Primary care practices are the intended audience to implement this tool as a way to facilitate practice change and better integrate reproductive health services for their patients. Practices and technical assistance providers could also leverage this data element to monitor and evaluate the extent to which care teams are implementing the screening tool within workflows. Two key initiatives that could utilize these data elements imminently are the federal Title X Family Planning Program and the non-profit technical assistance organization, Upstream USA.

Title X has included pregnancy intention screening in its encounter-level data reporting requirement, and has created both CCD-A and FHIR profiles that include pregnancy intention screening (12-14). Title X aims to collect this data element via interoperability standards by 2025. Title X serves between 1.5-4 million patients of reproductive age per year through approximately 100 grantee organizations.

Upstream USA is a nonprofit working to reduce unintended pregnancy by expanding access to contraception. Upstream currently collects these data elements via two data aggregation vendors that use proprietary software as well as interoperability standards (CCD). Upstream is exploring opportunities to collect these data via FHIR, state HIEs, and other options. Upstream has a goal of partnering agencies that serve one million female patients of reproductive age per year by 2024 (15).

12) https://omb.report/icr/202106-0990-002/doc/112357201
13) http://build.fhir.org/ig/hspc/ACOG-OPA-IG/output/
14) https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_FPv2.pdf
15) https://upstream.org/about/
Link to use case project page https://opa.hhs.gov/research-evaluation/title-x-services-research/family-planning-annual-report/fpar2 ; https://upstream.org/
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Pregnancy Intention Screening Question: Pregnancy intention in the next year - Reported
LOINC:86645-9
Example answer list:
Answer
Yes, I want to become pregnant; LA26438-4
I'm OK either way; LA26439-2
No, I don't want to become pregnant; LA26440-0
Unsure; LA14072-5

SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22


https://loinc.org/86645-9/
Additional Specifications There are technical specifications for FHIR and C-CDA profiles that utilize pregnancy intention screening (LOINC 86645-9).

FHIR Profile: http://build.fhir.org/ig/hspc/ACOG-OPA-IG/output/
The HHS/Office of Population Affairs OPA has created this FHIR standard and implementation guide to collect a set of standardized and agreed upon data elements from all encounters across the 4,000 Title X clinical sites in its project called FPAR 2.0 (https://opa.hhs.gov/research-evaluation/title-x-services-research/family-planning-annual-report/fpar2). Pregnancy intention screening is included in the list of FPAR 2.0 data elements (https://omb.report/icr/202106-0990-002/doc/112357201).

C-CDA technical framework: https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_FPv2.pdf
IHE Quality, Research, and Public Health Technical Framework Supplement, Family Planning version 2 (January 7, 2020). Version 1 of this profile was successfully tested by five vendors at the 2015 IHE Connectathon (16, 17).

16) https://www.healthit.gov/techlab/ipg/node/4/submission/146
17) Matney, S., Heale, B., Hasley, S. Lessons Learned in Creating Interoperable Fast Healthcare Interoperability Resources Profiles for Large-Scale Public Health Programs. Appl Clin Inform. December 2018; 10:87-95. https://doi.org/10.1055/s-0038-1677527
Current Use In limited use in test environments only
Supporting Artifacts As noted above, HHS/OPA tested the pregnancy intention screening LOINC and SNOMEDCT codes within testing environments for its FHIR profile and it has built this data element into its encounter-level annual reporting requirement (FPAR 2.0).

Working through its health agency partners, Upstream USA has embedded pregnancy intention screening tools into at least 15 different EHR vendor systems in WA, MA, RI, and NC (internal data). Upstream USA utilizes two healthcare data aggregation and visualization platforms (Azara Healthcare and IMAT) to collect pregnancy intention documentation rates to monitor practice change at its partner health-providing agencies.

Matney Lessons Learned in Creating Interoperable Fast Healthcare.2019.pdf
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) The LOINC code for screening for pregnancy intention is not proprietary. There are multiple screening tools for assessing patient pregnancy intention. One tool, One Key Question(R), is copyrighted by the organization Power to Decide and needs to be implemented according to their rules and regulations. This application is not advocating for use of any specific pregnancy intention screening tool, rather it is advocating for the general PISQ LOINC code to be adopted by USCDI.
Restrictions on Use (e.g. licensing, user fees) No known restrictions on using this data element.
Privacy and Security Concerns No known privacy and security concerns above and beyond the normal requirements to ensure that data elements are shared only with entities that have active data use agreements and the infrastructure to securely exchange PHI/PII.
If extra caution is desired, an entity may be able to collect whether a response to pregnancy intention screening exists in a patient’s record within a desired timeframe and could decide not to collect the exact patient response to the screening question.
Estimate of Overall Burden The burden to implement this data element is related to the level of effort it would take to build out a field in the EHR template and level of effort to train primary care teams to integrate this screening into their workflow. Care teams would also need to be trained on how to provide patient-centered reproductive health services such as contraceptive counseling as a follow-up to the screening. Some EHR vendors have family planning-related templates available to their clients, and such templates may include a pregnancy intention screening tool. Epic, NEXTGEN, and OCHIN Epic may include a field for this data element.

How hard is it to access and provide the data?
If a structured field is available for care teams to input this data element, it would not be difficult to access or send this data.

Is it only available in an outside system, such as a lab reporting system?
This data element is intended to be used in outpatient primary care settings.

Does it need to be calculated by the patient or provider, or can it be automatically retrieved or calculated by the system in a production environment?
This data element can be automatically retrieved via its LOINC code and/or SNOMEDCT response codes.

Does it require significant time on the part of patient or provider to access or record or does it require an interruption in normal workflow to capture?
This data element must be integrated into the primary care and reproductive health encounter workflows. Reproductive health services and contraceptive care are essential to the health and wellbeing of all patients of reproductive age. Such services should be accessible at a patient’s preferred point of care and not only within specialty settings.

Does it require significant developer time to implement in EHR systems?

If there is not yet a field available in the primary care workflow, a developer would need to build it out. In Upstream’s experience, determining where to put the field so that it is accessible to the right care team members at the right time in the workflow takes more time than building out the actual field. The process of identifying the right location and completing the build may take 2-3 months of collaboration.
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 1 - Data element is captured, stored, or accessed in at least one production EHR or HIT module.
Criterion #3
Maturity - Current Exchange		 Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 1 - Use cases apply to several care settings or specialties.

Comment

Submitted by edecker on

Request for Re-Evaluation for Level of PISQ

Upstream USA respectfully requests that this data element be re-evaluated for level. The information presented in the original data element application and comment dated 9/1/2022 still hold, and the need for it to become fully adopted in USCDI is urgent. Since the last public comment period, the HRSA Health Center Program has proposed pregnancy intention screening as a required UDS reporting data element. The Health Center Program is comprised of a network of over 1,400 health centers and 15,000 clinical service delivery sites. The program served 30.5 million patients in 2022, over 7.6 million of which were females of reproductive age (15-44 years). With this reporting requirement all 7.6 million female patients of reproductive age could be screened for their need for reproductive health services, and health centers may leverage the pregnancy intention screening question as part of this reporting requirement. 

Title X reporting continues to capture pregnancy intention screening. All Title X grantees will report encounter-level data, including PISQ, beginning with the 2022 reporting period. 

Approximately 37% of the Title X network are also part of the HRSA Health Center Program. Upleveling this data element will be even more beneficial to these dual grantees who are beginning to report encounter-level data via Title X’s FPAR 2.0 and UDS+ reporting requirements. 

Upstream USA continues to offer pregnancy intention screening to healthcare partners as one way to begin a contraceptive care workflow. We have embedded PISQ into at least 15 different vendor systems across the U.S. Vendor instances include Epic, Centricity, Intergy, and eClinicalWorks systems. PISQ is exchanged between these systems and Upstream’s data aggregation and visualization platform vendors, Azara Healthcare and IMAT. 

Submitted by harr0303 on

Support of Adding Pregnancy Intention Screening Question (PISQ)

The Sexual and Reproductive Health Program at the Washington State Department of Health supports this application and encourages the committee to re-evaluate this data element's level. PISQ is an important component of reproductive health workflows, and its inclusion in USCDI will further support access to person-centered reproductive health care at the Washington State Department of Health and beyond.”

Submitted by lmsatterf on

Support for Pregnancy Intention Screening in USCDI - ACOG

The American College of Obstetricians and Gynecologists (ACOG) represents over 60,000 obstetrician-gynecologists and partners in women's health and those that seek obstetric and gynecologic services. As such, ACOG strongly supports including pregnancy intention screening in the United States Core Data for Interoperability (USCDI), and requests that the committee re-evaluate this data element's level. Pregnancy screening is a key component of reproductive health care and its inclusion in USCDI will further assist physicians providing this essential care to their patients. Prepregnancy care, and pregnancies as a result of counseling and planning, supports improved maternal and infant health outcomes. Additionally, including the pregnancy intention screening in the USCDI will improve the ability of physicians and facilities to safely and appropriately share the necessary data to provide care coordination and shared decision making between patients and their physicians. 

Submitted by todonnell on

AAFP Comments on Pregnancy Intention Screening in USCDI

On behalf of the American Academy of Family Physicians (AAFP), representing 127,600 family physicians and medical students across the country, I write to submit comments in support of including pregnancy intention screening in the United States Core Data for Interoperability (USCDI). Last year, Upstream submitted an application for the Pregnancy Intention Screening Question (PISQ) to be included in the USCDI. The AAFP supports this application and encourages the committee to re-evaluate this data element's level. PISQ is an important component of reproductive health workflows, and its inclusion in USCDI will further support access to person-centered reproductive health care.

Prepregnancy care is individualized care for people considering pregnancy, which focuses on reducing morbidity and mortality for the patient and fetus, increasing the chances of conception when pregnancy is desired, and providing contraceptive counseling to help prevent unintended pregnancies. The AAFP supports prepregnancy care as it offers family physicians and their patients an opportunity to discuss any risk factors, minimize them before pregnancy, and work toward improved pregnancy-related and fetal outcomes.

The AAFP supports robust data sets with uniform standards and a national system of interoperability to facilitate efficient information sharing between patients, their family physicians, and their care team. Including the PISQ in the USCDI will improve data sharing, care coordination and shared decision making between patients and their primary care physicians. Thank you for your consideration of our comments. If you have any questions, please contact Meredith Yinger, Manager of Regulatory Affairs at myinger@aafp.org. Sincerely, Sterling N. Ransone, Jr., MD, FAAFP Board Chair, American Academy of Family Physicians

AAFP Comments to ONC on Pregnancy Intention Screening in USCDI 9 27 2022.pdf

Submitted by amastrangelo on

Support for PISQ added to USCIS

Harbor Health Services Inc supports this application and encourages the committee to re-evaluate this data element's level. PISQ is an important component of reproductive health workflows, and its inclusion in USCDI will further support access to person-centered reproductive health care at Harbor Health and beyond. Thank you for your consideration.

Submitted by Kevin Fairley … on

Support of Pregnancy Intention Screening from Azara Healthcare

Azara Healthcare LLC., supports the efforts of Upstream USA’s submission to add the Pregnancy Intention Screening Question (PISQ) data element into the US Core Data for Interoperability (USCDI) set. We provide a data analytics platform to health center practices, including many Federally Qualified Health Centers across the U.S.. Over the past years of our partnership with Upstream USA, the Pregnancy Intension Screening has been added to the EMRs, documented as part of center workflows, and loaded into our DRVS application where measurement of rates of contraceptive provision and counseling can be compared against the intention for pregnancy provided by those centers' patients. The Pregnancy Intention Screening Question (PISQ) data element is used by and connected to DRVS in 78 distinct health care practices, using 15 distinct EMRs. The data element has been documented 377,892 times in the past year. Please note that we consider the Pregnancy Intention Screening Question (PISQ) data element as a core part of our product, and encourage its consideration for addition into the US Core Data for Interoperability (USCDI) set.

Submitted by mariekristensen on

Support for PISQ Screening

As an FQHC that serves an 85% uninsured population, Charlotte Community Health strongly supports the PISQ screening. It has been used at our clinic for the past year and has lead to more empowerment of our female patients. By asking the question, we are empowering women to understand they have a choice. It has lead to more conversations around planned versus unplanned pregnancies and we have not seen it increase our staff workload burden. We strongly support this becoming a universal screening.

Marie Kristensen, FNP-bc, Assistant Medical Director at Charlotte Community Health 

Submitted by Robin Watkins on

Support for re-evaluation from Power to Decide

Power to Decide continues to support this application and encourages the committee to re-evaluate this data element's level. Screening for pregnancy desires supports individuals to achieve reproductive well-being by allowing providers to connect individuals to the health care they need to both prevent and achieve pregnancy on their own terms and timeline. Integrating pregnancy desire screening into reproductive health workflows with a standardized tool and training allows providers to mitigate the influence of unconscious bias, further supporting access to person-centered reproductive health care and improving patient satisfaction.

Submitted by edecker on

Request for Re-evaluation for Level

Upstream USA respectfully requests that this data element be re-evaluated for level. We believe that it meets the criteria for inclusion in USCDI as Level 1/2, based on the information in the original application, summarized here:

Use Case

  • Pregnancy intention screening is a well-known, person-centered approach used in Primary Care and OB/GYN settings to ensure that patients of reproductive age are offered information and services to help them achieve their desired reproductive goals, including pregnancy prevention or achievement.
  • A best-in-class workflow for contraceptive care begins with pregnancy intention screening and includes contraceptive counseling and documentation of contraceptive method provision or use. Of those data elements, only pregnancy intention screening is not currently included in USCDI. Including PISQ in USCDI would allow for exchange of data elements in the patient-facing contraceptive care workflow.
  • Monitoring pregnancy intention screening rates alongside contraceptive counseling provision and contraceptive method use allows for robust analysis of contraceptive care workflows in quality improvement contexts.
  • More than 99% of women of reproductive age who have been sexually active have used at least one method of contraception, and screening patients for pregnancy intention is one way to begin a workflow that integrates contraceptive care and ensures patients can access these services.

Standard Status

  • The Pregnancy Intention Screening Question (PISQ) data element has a LOINC code and answer list, and is also included in a LOINC panel for pregnancy information.
  • There are no copyright restrictions on the PISQ data element. It can be used by any entity.
  • PISQ is included in the IHE C-CDA profile for FPAR 2.0, which was successfully tested at the 2015 IHE North American Connectathon in Chicago by five EHR vendors: Mitchell and McCormick, Netsmart, Patagonia, GE Centricity, and one international EHR vendor. The C-CDA specification remains an option for Title X grantees to submit encounter-level data as part of FPAR 2.0.
  • PISQ is included in the FHIR Implementation Guide and accompanying profiles.
  • Pregnancy intention screening is fundamentally different from the Pregnancy Status data element in USCDI, which only captures positive or negative pregnancy findings and not whether the patient had desired or not desired pregnancy.

Current Exchange

  • This PISQ data element is part of a federal reporting requirement: the HHS/Office of Population Affairs Family Planning Annual Report 2.0 (FPAR 2.0) for Title X Family Planning Program Grantees. All Title X grantees will report encounter-level data, including PISQ, beginning with the 2022 reporting period. 
  • As of 2020, there were 75 Title X grantees with a network of 3,031 clinical service sites that provided care to over 1.5 million patients of reproductive age. These grantees will be exchanging encounter-level data including PISQ as part of 2022 FPAR 2.0 reporting.
  • PISQ is included as a data element in the CDC-funded Women’s Health Project to advance Postpartum Care Services, a partnership with the National Association of Community Health Centers and two Health Care Controlled Networks (HCCNs): Alliance Chicago and OCHIN Epic. Participating health centers exchange this data element with their respective healthcare controlled network.
  • Working through its health agency partners, Upstream USA has embedded PISQ into at least 15 different vendor systems in WA, MA, RI, and NC. Vendor instances include Epic, Centricity, Intergy, and eClinicalWorks systems. PISQ is exchanged between these systems and Upstream’s data aggregation and visualization platform vendors, Azara Healthcare and IMAT. 
  • PISQ is also known to be available widely within templates in OCHIN Epic and NextGen.

Submitted by Robin Watkins on

Comments from Power to Decide

Power to Decide, the campaign to prevent unplanned pregnancy, strongly supports the pregnancy intention screening question (PISQ) submitted by Emily Decker / Upstream USA. We appreciate the opportunity to submit these comments and respectfully offer the following recommendations in the attached document. 

PISQ Comments - Power to Decide 2021.pdf

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