Preserving Clinical Context

General Comments:

USCDI specifies lots of clinical data classes and data elements

  • Resolving to myriad de-coupled fragments
  • With vanishingly little focus on:
    • Clinical context and vital inter-relationships, e.g., between problems, diagnoses, complaints, symptoms, encounters, history and physical findings, allergies, medications, vaccinations, assessments, goals/objectives, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, outcomes, protocols, care plans and status...
    • Elements and context + purpose of capture:  e.g., blood pressure, its measurement (systolic, diastolic), its unit of measure (mm/Hg), its reason for capture, its context of capture (sampling site, sampling method, patient position, at rest/during/post exercise...

It is crucial to consider, determine and resolve how clinical content and context are bound together and preserved in USCDI.  The ultimate end user (often a clinician) must be able to readily discern context and inter-relationships – otherwise USCDI places an undue (and often unresolvable) burden on this user.  Only the source EHR/HIT system can structure clinical content and context properly.  Once data is stuffed into the USCDI framework and related exchange artifact (e.g., FHIR resources) this opportunity is forever lost.

May be underestimating the…

May be underestimating the adoption level. Vital signs are nursing variables and they are required by Meaningful Use. Other nursing variables like Braden scores are also common - so maybe two bubbles.

Regenstrief - Comment

We concur with the recommended standards here (LOINC and SNOMED CT). The second sentence in Limitations, Dependencies, and Preconditions for Consideration should be amended because it only applies to SNOMED: Concepts for observation values from SNOMED CT should generally be chosen from two axes: Clinical finding and Situation with explicit context.

Question / Answer Pairs

Question / Answer pairs are valuable, supporting context of the assessment.  The assessment should not be limited to Q/A pairs. Full question with answer must be included in communication.

We strongly approve of Nursing practice being included in ISA.  

Agree with use of name/value pairs

The Joint Commission agrees with the use of name/value pairs to represent clinical assessments.  This is the current structure used in electronic clinical quality measures (eCQMs).