|Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)|
|Data Element Information|
|Rationale for Separate Consideration||USCDIv1 includes medical services that are complete (procedures, labs) and Plan of Treatment, but not orders for services. Services not provided by the same organization where ordered requires a transfer of a patient with the relevant order information.|
|Use Case Description(s)|
|Use Case Description||Orders (service requests) are used extensively by hospitals, clinicians and providers as part of the quality measurement. They are important for quality improvement, clinical decision support and measurement to understand the link between things ordered and then completed/administered. These data are necessary to confirm appropriate and high quality of care is received for patients across different populations. It is clinically relevant from a care perspective and a quality measurement perspective to distinguish information about services orders, and those completed.
Currently, CMS quality measures include the following order concepts. Orders for:
• Labs and diagnostic studies
• Interventions (i.e. hospice, comfort care, palliative care) and procedures
|Estimate the breadth of applicability of the use case(s) for this data element||More than 4,00 hospitals and 1 million providers currently capture, access and exchange this order (service request) information. This information is currently electronically submitted by providers and hospitals to CMS for quality measurement.
eCQI resource center, includes measure specifications for CMS program eCQMs (i.e. CMS 125, CMS 71, CMS 645): https://ecqi.healthit.gov/ecqms
|Link to use case project page||https://ecqi.healthit.gov/ecqms|
|Use Case Description||Each step in the chain of events between a clinician’s request for a service (order) and the completion of that service is critical for vigilance and surveillance of patient safety and appropriate care. It is important to have the capacity to evaluate the clinician’s intent, the actual completion across care settings and across time. Specifically, this concept allows for transfer of information of the order to be completed, if the service is not being provided by the same organization.|
|Estimate the breadth of applicability of the use case(s) for this data element||All healthcare providers, laboratories, hospitals using EHR systems should have order information documented and accessible.|
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||Orders reference services available in standardized terminology:
Intervention order (Comfort measures): SNOMEDCT
Device order: SNOMEDCT
Diagnostic study, laboratory test order: LOINC
Encounter/follow-up order: SNOMEDCT
|Additional Specifications||HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request: http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-servicerequest.html
CMS Quality Data Model (QDM) version 5.5 Guidance, orders (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf)
US CORE Implementation Guide: Service Request noted as a future potential profile: https://www.hl7.org/fhir/us/core/future-of-us-core.html
|Current Use||Extensively used in production environments|
Orders (service requests) are routinely captured in EHR systems used by hospitals and providers for the use in CMS quality reporting eCQMs across programs including IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of order (service request) related data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes order (service requests) for a procedure, diagnostic service, intervention, laboratory test, or other planned service for a patient.
|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.|
Orders (service requests) 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 architectures. These orders (service requests data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
|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 element.|
|Estimate of Overall Burden||Orders (Service requests) are regularly captured by a broad range of healthcare providers, and should not cause burden to implement. Some burden required to include a ServiceRequest profile as a US Core profile, though it is already noted as a potential addition for future iterations, and built out in QI Core.|
|Other Implementation Challenges||N/A|
Types of orders for medical care/services
Order or a Service Request represents a request for a procedure, diagnostic service, intervention, laboratory test, follow-up care, or other planned service for a patient. This concept may be used to share relevant information required to support a referral or a transfer of care request from one practitioner or organization to another when a patient is required to be referred to another provider for a consultation /second opinion and/or for short term or longer-term management of one or more health issues or problems.