CMS-CCSQ Support for Facility Identifier for USCDI v5

CMS-CCSQ is pleased to see that Facility Identifier data element was added to USCDI v4. However, we recommend that the Facility Identifier data element be limited to capturing an individual facility instead of an organization or health system (with multiple facilities). We also recommend the NHSN OrgID be added to the Facility Identifier data element in addition to existing standards to capture individual facilities. This recommendation is a slight change from the CMS-CDC recommendation for draft USCDI v4 where NHSN OrgID was recommended under the Organization/Hospital Identifier. Additional discussion amongst CMS and CDC concluded that NHSN OrgID can more adequately capture an individual hospital or individual facility and that the CCN, which is currently in the Facility Identifier data element, is more appropriate as an organizational identifier.

NCPDP Comment

NCPDP supports the use of the Type 2 NPI and recommends this to be added to the data elements. NCPDP recommends adding the following NCPDP SCRIPT Standard v2017071, NCPDP Specialized Standard v2017071 and NCPDP Telecommunication Standard Version D.0 as “Applicable Standard(s)”.

CAP Comments on Facility Identifier

• Data Class: Facility Information
• Data Element: Facility Identifier
• CAP Comment: The College of American Pathologists (CAP) supports this data element and finds that this element can capture the necessary information about Laboratory Address and Location. The CAP recommends that this data element should include identifier information number for facilities. If the facility type is a medical laboratory then a CLIA number should be used to unambiguously identify the laboratory.

CDC's Consolidated Comment for USCDI v4

Shared priority for CDC, CMS, and ASPR (via all hazards work with CDC)

• Facility Identifier is necessary for measuring care delivered to inpatients and properly attributing that care. Facility identifier is critical for providing context for granular patient data and supports tracking data back to organizations, which ensures usability of interoperable clinical data. They can also support exchange of data between hospitals and post-acute care providers. All these activities are necessary for providing high quality care to patients, reducing healthcare inequities and disparities, and promoting interoperability and communication – all ONC stated priorities for the USCDI.
• Facility identifiers have been identified as a joint CMS-CDC priority that are critical elements for public health reporting, surveillance, and emergency response (also ONC stated priority for USCDI v4).
• CCN, PTAN, NPI, NHSN OrgID, and CLIA numbers are exchanged across the nation for CMS reporting to appropriately attribute outcomes and measure results. Organization identifiers are also used to support public health use cases, including electronic case reporting and emergency response activities proving applicability across multiple use cases. Accurate facility identifiers are essential to analyze facility level data and inform the allocation of resources such as therapeutics, supplies, staffing, and PPE to prepare for and respond to emergency events.
• Facility names and addresses can be duplicative, so unique facility identifiers are critical to link facility-level primary key to link HAI data collected in NHSN to facility-level COVID-19 hospitalization data collected through the Unified Hospital Data Surveillance System. Linking these data systems is crucial for understanding the impact of COVID-19 on patient safety and other healthcare measures
• The ISWG recommended this element for final USCDI v3, and received HITAC support, noting the need for an identifier combined with an assigning authority

  

• Additional use cases:

1. COVID-19 hospital reporting
2. All hazards reporting
3. HAI
4. Patient safety quality measurement and public health surveillance via NHSN

•  Comments from NACCHO: NACCHO supports the inclusion of this data element; NACCHO recommends specifying which facility identifier should be used. Facilities could use multiple identifiers depending on the EHR system. A standard identifier should be used in this data element. Otherwise, an additional element should be added in Facility Information that indicates what identifier is used
•  Comments from CSTE: CSTE agrees with CDC's recommendation for this data element.

CMS-CCSQ Support for Facility/Organization Identifier: USCDI v4

A facility, or organizational, identifier is critical for providing context for granular patient data and supports tracking data back to organizations—this type of contextual data element ensures usability of interoperable clinical data. Facility identifiers are used for billing, support data aggregation across sources, as well as attribution. They can also support exchange of data between hospitals and post-acute care providers. All of these activities are necessary for providing high quality care to patients, reducing healthcare inequities and disparities, and promoting interoperability and communication – all ONC stated priorities for the USCDI. Facility identifiers were also previously identified as a joint CMS-Centers for Disease Control and Prevention (CDC) priority as a critical element for public health reporting, surveillance and emergency response – an ONC stated priority for USCDI v4. For example, CDC and CMS rely on facility identifiers to measure the incidence of healthcare associated infections and other patient safety events in facilities, and to direct technical assistance and quality improvement support to underperforming facilities. Furthermore, the ISWG recommended this element for final USCDI v3, and received HITAC support, noting the need for an identifier combined with an assigning authority. Maturity: This element is classified as Level 2 by ONC and continues to have strong standardization and be in wide use.

• Current standards:
  • Health Level Seven International (HL7) Fast Healthcare Interoperability Resources (FHIR) US Core Implementation Guide (IG) STU3-STU5 based on FHIR R4, Organization Profile must support an identifier (https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-organization.html)
  • Organization Profile is included in the HL7 FHIR US Core Capability Statement: https://www.hl7.org/fhir/us/core/CapabilityStatement-us-core-server.html; data included in this profile must be able to be exchanged, including the Organization Identifier

Current uses, exchange, and use cases: CCN, PTAN, NPI, and CLIA numbers are exchanged across the nation for CMS reporting to appropriately attribute outcomes and measure results. They are used extensively for electronic clinical quality measure (eCQM) reporting, linking data sources for quality measurement, and for post-acute care reporting and payment purposes. Facility identifiers are also used extensively for electronic case reporting (eCR) and electronic lab reporting (ELR) and are critical for public health agencies ability to monitor the spread of reportable conditions. Exchange of organization identifiers supports facility-specific quality, prior authorization activities, and other assessments that are limited without this information. Additionally, there is active work underway to create an IG for healthcare directories (HL7.FHIR.US.DIRECTORY-EXCHANGE\Home - FHIR v4.0.1) as part of the FAST Da Vinci accelerator initiative, which includes the critical organization and provider identifiers necessary to appropriately use and attribute exchanged data. Among other purposes, organization identifiers are also used to support public health use cases, including electronic case reporting and emergency response activities. For instance, during the early COVID-19 pandemic phase, there was insufficient data tracking across organizations, further complicated by the need to track emergency response resources across individual facilities. Exchange of facility/organization identifiers can mitigate such delays in emergency response activities.

CDC's comment on behalf of CSTE for USCDI v4

CSTE agrees with CDC's recommendation for this data element.

CDC-CMS Joint Priority Data Element for USCDI v4

We support the CMS comment ‘CMS-CCSQ Support for Facility/Organization Identifier: USCDIv3’ on 2022-03-22 that Facility/Organization Identifiers are critical component of EHR for providing high quality care to patients, reducing disparities, SDOH data analysis, promoting interoperability and data aggregation. HIPAA requires that health care providers have standard NPI that identify them on all standard transactions.  We recommend adding the ‘Facility/Organization Identifiers’ to USCDI data classes. We suggest the following definition of this data class: ‘Facility/Organization Identifiers in EHRs are standardized codes, names and other attributes that provide a unique data pointer to a healthcare facility/organization where patient’s care has occurred.’  We found a similar concept description in the Level 2 under the ‘Facility Level Data’. Because a potential ambiguity of the ‘Facility Level Data’ term (i.e., it could mean aggregate level facility data rather than unique identifiers) we strongly suggest replacing it with proposed by CMS title ‘Facility/Organization Identifiers’. Based on the recent experience in management of the COVID-19 EHRs and ONC requirements on EHR aggregation and reporting data for situational awareness, we propose that the following data elements and associated vocabulary standards should be included into the Facility/Organization Identifiers data class:

1. Organization/Facility name, LOINC 76469-6
2. Organization/Facility Email address, LOINC 90054-8
3. Organization/Facility Phone number, LOINC 90053-0
4. Organization/Facility Address, LOINC 90052-2
5. Organization/Facility ZIP code , LOINC 76695-6
6. National Provider ID (NPI), LOINC 45952-9
7. CCN (CMS Certification Number), LOINC 69417-4

Additional applicable standards and additional specifications:

1. FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type https://bit.ly/FHIRLocation,
2. Resource Profile: FHIR 5.0.1 - STU5 Release US, US Core Location Profile  https://open.epic.com/Interface/FHIR#Location
3. FHIR 4.3.0: R4B – STU, Resource Organization - Detailed Descriptions     https://hl7.org/fhir/organization-definitions.html
4. HHS.gov. Health Information Privacy. Other Administrative Simplification Rules. https://www.hhs.gov/hipaa/for-professionals/other-administration-simplification-rules/index.html

This element is also shared priority for both CDC and CMS as outlined in the joint support letter

CDC-CMS Joint Priority Data Element

 Both CDC and CMS support inclusion of this element in v3. More details are provided in the joint letter sent to ONC. 

CMS-CCSQ Support for Facility/Organization Identifier: USCDIv3

Identifiers are critical for billing, linking billing/clinical EHRs, supporting data aggregation across data sources and reducing burden, as well as attribution and tracking of data. All of these activities are necessary for providing high quality care to patients, reducing disparities, promoting interoperability and communicating across silos. Facility identifiers are also critical for public health reporting and tracking, an ONC stated priority for USCDI version 3. CMS specifically prioritizes exchange of CMS Certification number (CCN), Provider Transaction number (PTAN), and National Provider Identifier (NPI)—unique identifiers for a healthcare organization. Maturity:

• Current standards:
  • HL7 FHIR US Core Implementation Guide STU3 and STU4 based on FHIR R4, Organization Profile must support an identifier (https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-organization.html )
  • Organization Profile is included in the HL7 FHIR US Core Capability Statement: https://www.hl7.org/fhir/us/core/CapabilityStatement-us-core-server.html; data included in this profile must be able to be exchanged, including the Organization Identifier
• Current uses, exchange, and use cases: CCN, PTAN, and NPI are exchanged across the nation for CMS reporting to appropriately attribute outcomes and measure results.  Exchange of these identifiers supports facility-specific quality, prior authorization activities, and other assessments that are limited without this information.

Unified Comment from CDC

• General Comment: This comment supports the promotion of the Data Class Patient Demographics - Data Element Identifier to USCDI V3 as well as the additional Data Element of Identifier System, including the allowance of multiple instances of Identifier/ Identifier System pairs per patient (approach 1). We believe that this will allow needed flexibility to accommodate use and exchange of the variety of patient identifiers in current use in the US. An example of this approaches is: Identifier: 333224444, Identifier System: http://hl7.org/fhir/sid/us-ssn.  
• If ONC does not choose to incorporate approach 1, (Identifier + Identifier System), in USCDI V3, we recommend allowing for the following Patient Demographic Data Class Data Elements in USCDI V3: Medicare Patient Identifier, Medical Record Number and Social Security Number. (approach 2) We believe that allowing for both approaches would be confusing, so we recommend choosing one or the other.  
• Additional Use Case: This is a standard data (FIN or NPI) item used by central cancer registries in all states according to the North American Association of Central Cancer Registries (NAACCR) standard. Data received through data exchange from medical facilities (e.g., laboratories, hospitals, physician EHRs, etc.) to central cancer registries for CDC and NCI’s national cancer surveillance systems, as required by law.    
• CSTE supports inclusion of this measure into USCDI v3: Very useful for this information to be captured in some way and then subsequently used in reporting to PH.