Data Element
Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Use Case Description(s)
Use Case Description Encounter information is used extensively by hospitals, clinicians and providers submitting data for quality measurement. This patient level encounter information provides context for when, why and what type of healthcare encounters occurred which may have led to conditions diagnosed, procedures performed, or medications prescribed. It is used in quality measurement to define a population for measurement based on time of encounter occurrence, and encounter reason, or the location within a hospital an encounter occurred.
It is also critical context for clinicians interpreting transferred information. For example, contextualizing an eGFR measure during an acute care hospitalization excludes it from use in categorizing a patient’s stage of chronic kidney disease. For quality assessment, the context of encounters is the cornerstone of attribution and accountability for performance.
Estimate the breadth of applicability of the use case(s) for this data element More than 4,000 hospitals and 1 million providers are currently capturing, accessing and exchanging this encounter level information. This information is currently electronically submitted by providers and hospitals, or their Health IT firms/EHR vendors, to CMS for quality measurement.
Link to use case project page https://ecqi.healthit.gov/ecqms
Use Case Description Data exchange of encounter information is also critical for clinical care. Clinicians need to be aware of recent healthcare encounters, including the type of encounter, the reason for the visit, how recent that encounter was (date/time) and discharge disposition and diagnosis in order to provide relevant and quality care for the patient thereafter.
Currently, this type of encounter information is exchanged as part of care coordination and admission/discharge/transfer notifications as part of ONC interoperability standards.
Estimate the breadth of applicability of the use case(s) for this data element All healthcare providers using certified electronic health record technology (CEHRT) should be capturing, accessing, using and exchanging these encounter data elements.
Link to use case project page https://www.healthit.gov/isa/section-ii-contentstructure-standards-and-implementation-specifications
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Encounter type/occurrence:
SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307)
HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087)
CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001)
HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html
Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis:
SNOMED CT
ICD-10-CM
Discharge Disposition:
DischargeDisposition
Code System http://terminology.hl7.org/CodeSystem/discharge-disposition

Encounter Location:
SNOMED
HSLOC

https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
Additional Specifications HL7 FHIR US Core Implementation Guide STU3 based on FHIR R4, Encounter profile. (https://www.hl7.org/fhir/us/core/index.html) Encounter status, class, type, period (timing), reason, location, discharge disposition all must have/must support data elements
This Encounter profile is also required by the US Core IG Capability Statement. (https://www.hl7.org/fhir/us/core/capstatements.html)
CMS Quality Data Model (QDM) version 5.5 Guidance (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf)
HL7 C-CDA Release 2.0 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492)
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Encounter data is routinely captured in EHR systems used by hospitals, providers, and other healthcare stakeholders. Encounter-based EHR data is submitted by providers to CMS via QRDA I and III files and other data architectures from hospitals, providers, health IT firms, and vendors for eCQM public reporting in CMS IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of patient and encounter based data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes encounter details including admission and discharge date/times or office visit date/times to determine which patients are included in the measurement periods, type of encounter, and encounter diagnoses/primary reason, discharge dispositions, and encounter location details to determine the population of interest, or measure exclusions.
Widely available in EHR systems:
https://fhir.cerner.com/millennium/r4/encounters/encounter/
https://open.epic.com/Interface/FHIR
https://mydata.athenahealth.com/fhirapidoc

Links:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
https://ecqi.healthit.gov/ecqms

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
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.
Supporting Artifacts Encounter 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 data architectures. These encounter data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly electronically captured and exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
Encounter data has also been electronically exchanges with external organizations via C-CDA, as part of ONC’s requirements and a part of data exchange for the continuum of care to notify of admissions, discharges, and transfers of care.

Links: https://ecqi.healthit.gov/qrda
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
https://www.healthit.gov/isa/support-a-transition-care-or-referral-another-health-care-provider
https://confluence.hl7.org/display/FHIR/2020-09+Clinical+Reasoning


https://ecqi.healthit.gov/qrda
Potential Challenges
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.
Estimate of Overall Burden Encounter data is regularly captured by a broad range of healthcare providers, and should not cause burden to implement. This data is already regularly exchanged and available in standardized fields and terminology. It is also required by the US Core Capability Statement and therefore will be stood up by those stakeholders complying with the ONC requirement for the Standardized FHIR API for patient and population services.
Other Implementation Challenges N/A

Comment

Submitted by joshualegler on

Emergency Medical Services Encounter Dispositions

If USCDI adopts or defines a value set, please include dispositions that are appropriate for emergency medical services (ambulance) encounters. An example would be “transferred to a hospital emergency department.” The following NEMSIS data elements may be helpful in ensuring that the value set adequately covers EMS encounter dispositions:

  • eDisposition.21 Type of Destination
  • eDisposition.27 Unit Disposition
  • eDisposition.28 Patient Evaluation/Care
  • eDisposition.29 Crew Disposition
  • eDisposition.30 Transport Disposition
  • eDisposition.31 Reason for Refusal/Release

This comment is submitted on behalf of the National Emergency Medical Services Information System (NEMSIS) Technical Assistance Center.
 

Submitted by LisaRNelson on

Encounter Disposition

In addition to the prior comments logged by Lisa Nelson on 2021-09-09, it is important to note that the encounter disposition data element is critical to new CMS mandates for the exchange of admission and discharge event notifications.

The CMS Interoperability and Patient Access Rule includes conditions of participation which mandate support for producing and receiving ADT notifications. These new requirements escalate the criticality of standardizing the expected vocabulary used to express the encounter disposition. This data element is established to represent the type of facility that a patient is discharged to following a hospitalization or episode of care.  Without a single common vocabulary for expressing this concept, the benefit of exchanging ADT notification is undermined.

The vocabulary selected to encode a data element can introduce barriers to interoperability. Guidance about the vocabulary to express the encounter disposition data element is inconsistent between V2, CDA and FHIR and in some cases it uses a vocabulary called NUBC UB-04 FL17-Patient Status which must be licensed for use by the National Uniform Billing Committee. These inconsistencies and licensing barriers act to block information exchange.

For the encounter disposition data element to be recognized as a Level 3 USCDI element, the vocabulary required when expressing the element needs to be well established and freely available for access. Without a single required value set which does not use codes that come from a vocabulary that imposes licensing restrictions, this element should not be recognized as a mature and implementable data element that supports interoperability.

USCDI V3 Comment 20220429.pdf

Submitted by LisaRNelson on

Encounter Disposition data element needs a definative value set

A single definitive value set needs to be defined to represent the range of concepts that are needed for expressing the Discharge Disposition data element.

The existing lack of alignment across V2, C-CDA, FHIR US Core and Quality Measures makes in difficult, if not impossible, to support interoperability. 

     Several code sets are in use that identify External Transfer scenarios. Initiating Systems SHALL use one of the following:

 

  1. The HL7 Value Set DischargeDisposition as stipulated in HL7 FHIR
  2. HL7 Table 112 codes referenced in the HL7 2.5.1 specification and referenced by C-CDA but under a different value set.
  3. SNOMED Codes used by quality measures for this same information

 

These code sets deal with the following discharge scenarios, along with others that are different and in some cases are more specific or overlapping in difficult ways:

  • Discharge to Home
  • Discharge to Skilled Nursing Facility
  • Discharge to Rehabilitation Facility
  • Discharge to Other Healthcare Facility
  • Discharge to Psychiatric Hospital
  • Discharge to Hospice
  • Discharge to Long-Term Care
  • Discharge to Alternative Home
  • Left against advice
  • Expired
  • Other

 

The problem is that the lists are not consistent and there is not reasonable way to map between them. 

See full ppt from January 2021 HL7 Work Group presentation summarizing the need to clarify a single definitive value set for this data element.

Value Set Alignment - Discharge Disposition 20210128.pdf

Submitted by JAndress316 on

Response to Comment on Encounter Disposition

We would need to consider capturing this variable in order to support the following domain related to Paul Coverdell National Acute Stroke Program/American Hospital Association’s (AHA) Get With The Guidelines (GTWG). The goal is to reduce gaps in stroke care across the continuum of care in states with high burden populations. • The information captured from stroke patients and those who encounter mobility related issues and are at risk of multiple hospitalizations due to post-discharge complications can help in reducing the gaps in care and to plan quality improvement efforts. # Domain # of Variables Variable Details Required or Optional 1 ED Visits 1 1. Was the patient admitted to hospital, discharged to home, discharged to SNF or other institutional long term care, or held for observation and then discharged? Optional • Currently the options displayed for “Encounter Disposition” data element are: discharged to home, discharged against medical advice, and or expired. We request the options to be expanded by including: admitted to hospital, discharged to SNF or other institutional long term care, held for observation, unknown/ND Use-Case Justification: The most challenging part is capturing the information post-hospital discharge for acute stroke patients. A lot of the pre-hospital care is captured through National Emergency Medical Services Information System (NEMSIS), a national database that stores EMS data from the U.S. States and Territories). The follow-up elements proposed above have been developed as a part of the Paul Coverdell National Acute Stroke Program (link provided below) and captured within EHR for submission into American Heart Association’s (AHA) Get With The Guidelines (GTWG) module. The ability to extract the follow-up encounter related dates would help with the identification of gaps in post-hospital discharge date for stroke patients and plan strategies for Quality Improvement efforts. https://www.cdc.gov/dhdsp/programs/stroke_registry.htm This field is for general comments on this specific data element. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC
USCDI_Version_2_Draft_Template for Comments_DHDSP_vFinal_04.14.2021_1.docx

Thank you for providing additional use cases for this data element. In the submission, CMS had noted a HL7 code system for discharge disposition (http://terminology.hl7.org/CodeSystem/discharge-disposition) which we believe encompasses many of the discharge dispositions noted in your comment. We agree that there are many important discharge dispositions that should be represented in the terminology standards to support care and coordination of care.

Submitted by nedragarrett_CDC on

Encounter Disposition

• We would need to consider capturing this variable in order to support the following domain related to Paul Coverdell National Acute Stroke Program/American Hospital Association’s (AHA) Get With The Guidelines (GTWG). The goal is to reduce gaps in stroke care across the continuum of care in states with high burden populations.
• The information captured from stroke patients and those who encounter mobility related issues and are at risk of multiple hospitalizations due to post-discharge complications can help in reducing the gaps in care and to plan quality improvement efforts.

# Domain # of Variables Variable Details Required or Optional
1 ED Visits 1 1. Was the patient admitted to hospital, discharged to home, discharged to SNF or other institutional long term care, or held for observation and then discharged? Optional

• Currently the options displayed for “Encounter Disposition” data element are: discharged to home, discharged against medical advice, and or expired. We request the options to be expanded by including: admitted to hospital, discharged to SNF or other institutional long term care, held for observation, unknown/ND

Use-Case Justification: The most challenging part is capturing the information post-hospital discharge for acute stroke patients. A lot of the pre-hospital care is captured through National Emergency Medical Services Information System (NEMSIS), a national database that stores EMS data from the U.S. States and Territories). The follow-up elements proposed above have been developed as a part of the Paul Coverdell National Acute Stroke Program (link provided below) and captured within EHR for submission into American Heart Association’s (AHA) Get With The Guidelines (GTWG) module. The ability to extract the follow-up encounter related dates would help with the identification of gaps in post-hospital discharge date for stroke patients and plan strategies for Quality Improvement efforts.
https://www.cdc.gov/dhdsp/programs/stroke_registry.htm

This field is for general comments on this specific data element. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC

USCDI_Version_2_Draft_Template for Comments_DHDSP_vFinal_04.14.2021_1.docx

Submitted by maria.michaels… on

MedMorph's support of Encounter Disposition

The MedMorph project supports the addition of this element but recommends a change in the definition to read: "The category or kind of location after discharge. For example, a patient may be discharged to home, discharged against medical advice, or expired."
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Applicable Standard for the data element: HL7 FHIR -  Hospital encounter discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
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