Comment

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, allergies, medications, vaccinations, assessments, clinical decisions, orders, results, diagnostic procedures, interventions, observations, treatments/therapies, referrals, consults, 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 and determine/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.

SNODENT free cost?

per link to snodent - the entry 'free' in cost is incorrect.

 

See the text on the website.

SNODENT is owned, maintained and distributed by the American Dental Association (ADA). The SNODENT code set is available under license at no cost for non commercial use. The license agreement terms also permit licensees to use SNODENT in the development of non-commercial, academic, scholarly articles and presentations for publication. For inquires about SNODENT licenses, use the contact information below.

 

 

Consider describing the license details in the preconditions section.