| Submitted By: Maria Michaels / CDC | |
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| Data Element Information | |
| Use Case Description(s) | |
| Use Case Description | Actively monitoring diseases, making decisions about public health threats, identifying trends in healthcare services utilization and other public health matters depend on accessible and accurate data. EHRs are a data source that can provide timely and relevant data beyond its use by health care providers. EHR data, if made more available for public health professionals and researchers, can lead to more rapid disease detection, tracking, and treatment and innovation in healthcare delivery. A patient's encounter with a provider of medical services, ranging from an ambulatory office visit with the patient's primary care provider, to a sudden, acute injury necessitating a trip to an Emergency Department to an admission to and subsequent discharge from a hospital for surgery is a fundamental organizing principle across the healthcare industry. The encounter class of data elements is widely used in EHRs and other systems for clinical care, payment purposes and operational efficiency. Beginning with the encounter status, often used as a trigger for clinical workflow, through classifying, numerically identifying and assigning a date and time to the encounter, to identifying the patient and provider subjects of the encounter as well as their roles form the structure of the encounter these encounter elements have varied clinical and administrative uses. The chief complaint, reason for visit and encounter diagnoses capture the richness of the encounter while the expected source of encounter payment and encounter discharge disposition provide information for follow up and payment. The majority of the candidate encounter data elements here are either mandatory or must support data elements of the US CORE Encounter Profile or Shall or Should data elements in many CDA use cases. The Making EHR Data More Available for Research and Public Health (MedMorph) project's goal is to create a reliable, scalable, and interoperable method to get electronic health record data for multiple public health and research scenarios (use cases). MedMorph has identified Cancer Registry Reporting, Healthcare Surveys, Electronic Initial Case Reporting (eCR), Hepatitis C Reporting, Birth Reporting and Research (PCORNet) use cases that support the adoption of these encounter data elements. These specific use cases are described in more depth on their respective web pages. |
| Estimated number of stakeholders capturing, accessing using or exchanging | All 50 states participate in one or more of the MedMorph public health and research use cases that exchange these encounter data elements. Up to 14 territorial or city jurisdictions also participate in one of these public health use cases and use these data elements. All hospitals and physicians who diagnose or treat cancer are required to provide encounter information to state cancer registries. Approximately 620,000 physicians in the US are active and have at least some component of ambulatory practice and thus are annually eligible to sampling and recruitment into the National Ambulatory Medical Care Survey (NAMCS), which samples from between 3,500 to 20,000 of these physicians annually. Presently each sampled physician submits one weeks' worth of patient encounters to NAMCS. Approximately 600 hospitals are in the National Hospital Care Survey (NHCS). 1/3 of that number are either in, or actively being recruited into, the EHR data submission mode for NHCS. NHCS is already receiving electronic CDA documents. When they reach their target of 200 hospitals submitting by this mode annually they will be receiving >1.2 million documents and sets including multiple sets of medication data annually. Related to birth reporting, every year there are approximately 3.7 million births in the United States. Consumption of this data is widespread. Every jurisdiction in the country captures birth certification information and immunization administration. Most also capture birth defects and fetal deaths. Healthcare systems that provide care for expectant mothers should be collecting this data. There were approximately 1,000,000 practicing physicians (as of 2020), approximately 120,000 certified physician assistants (as of 2019) and 290,000 licensed nurse practitioners (as of 2019). Most of these licensed clinicians interact with one of these public health use cases intermittently, annually. As of 2018 AHA reported 6,146 hospitals in the US experiencing 36,353,946 admissions. Almost all of those hospitals and many of the admissions interact with one or more of the public health and or research use cases. The vast majority of these exchanges include most or at least some of the encounter data elements contained in this submission. Supporting Links: MedMorph: https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html Cancer Reporting: https://www.cdc.gov/cancer/npcr/ Hepatitis C Reporting: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Health Care Surveys: https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm eCR: https://www.cdc.gov/ecr/index.html PCORnet: https://pcornet.org/ Birth Reporting: https://www.cdc.gov/nchs/nvss/births.htm |
| Link to use case project page | https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html Cancer Reporting: https://www.cdc.gov/cancer/npcr/ Hepatitis C Reporting: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Health Care Surveys: https://www.cdc.gov |
| Supporting Attachments |
MedMorph-HealthCareSurveyReportingUseCase-DRAFT.pdf MedMorph-CancerReportingUseCase-DRAFT.pdf MedMorph-ChronicHepatitisCSurveillanceUseCase-DRAFT.pdf |
| Use Case Description | A foundational goal of MedMorph is generalizability beyond the 10 use cases that are actively informing the MedMorph project, in order to support many more public health and research use cases. Therefore, other public health and research use cases that use the MedMorph architecture will also benefit from the adoption of these encounter data elements. |
| Estimated number of stakeholders capturing, accessing using or exchanging | All 50 states participate in one or more of the MedMorph public health and research use cases that exchange these encounter data elements. Up to 14 territorial or city jurisdictions also participate in one of these public health use cases and use these data elements. All hospitals and physicians who diagnose or treat cancer are required to provide encounter information to state cancer registries. Approximately 620,000 physicians in the US are active and have at least some component of ambulatory practice and thus are annually eligible to sampling and recruitment into the National Ambulatory Medical Care Survey (NAMCS), which samples from between 3,500 to 20,000 of these physicians annually. Presently each sampled physician submits one weeks' worth of patient encounters to NAMCS. Approximately 600 hospitals are in the National Hospital Care Survey (NHCS). 1/3 of that number are either in, or actively being recruited into, the EHR data submission mode for NHCS. NHCS is already receiving electronic CDA documents. When they reach their target of 200 hospitals submitting by this mode annually they will be receiving >1.2 million documents and sets including multiple sets of medication data annually. Related to birth reporting, every year there are approximately 3.7 million births in the United States. Consumption of this data is widespread. Every jurisdiction in the country captures birth certification information and immunization administration. Most also capture birth defects and fetal deaths. Healthcare systems that provide care for expectant mothers should be collecting this data. There were approximately 1,000,000 practicing physicians (as of 2020), approximately 120,000 certified physician assistants (as of 2019), and 290,000 licensed nurse practitioners (as of 2019). Most of these licensed clinicians interact with one of these public health use cases intermittently, annually. As of 2018, AHA reported 6,146 hospitals in the US experiencing 36,353,946 admissions. Almost all of those hospitals and many of the admissions interact with one or more of the public health and or research use cases. The vast majority of these exchanges include most or at least some of the encounter data elements contained in this submission. |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter:http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: http://www.ama-assn.org/go/cpt Encounter participant type: http://hl7.org/fhir/ValueSet/encou |
| Additional Specifications | HL7 CDA ® Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1, DSTU Release 1.1 – US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=398 HL7 CDA® R2 Implementation Guide: National Health Care Surveys (NHCS), R1 STU Release 3 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=385 HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492 HL7 FHIR® US Core Implementation Guide STU3 Release 3.1.1: https://www.hl7.org/fhir/us/core/index.html HL7 FHIR US Core Encounter: http://hl7.org/fhir/us/core/StructureDefinition-us-core-encounter.html. MustSupport for the following elements: Encounter status, Classification of Encounter, Encounter type, Encounter subject, Encounter Identifier, Encounter period, Encounter participant type, Participant overseeing the encounter, Primary participant responsible for encounter, Encounter participant individual, Encounter primary performer NPI, Encounter primary performer name, Encounter primary performer professional role, Time period participant participated in the encounter, Reason for the visit, Hospital encounter discharge disposition, Encounter location address HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm: http://hl7.org/fhir/us/ecr/STU1/Electronic_Initial_Case_Report_(eICR)_Transaction_and_Profiles.html HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 - US Realm - the Electronic Initial Case Report (eICR): https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 Vital Records Birth and Fetal Death Reporting FHIR - US Realm: https://build.fhir.org/ig/HL7/fhir-bfdr/index.html HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320 HL7 CDA® R2 Implementation Guide: Birth and Fetal Death Reporting, Release 1, STU (Release 2 - US Realm): https://www.hl7.org/implement/standards/product_brief.cfm?product_id=387 IHE Quality, Research and Public Health Technical Framework Supplement: Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1: (https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf) |
| Current Use | Extensively used in production environments |
| Supporting Artifacts |
Level 2 – at scale, or in more widespread production use (routinely collected already) on several different EHR/HIT systems. Widely available in EHR systems. These data elements exist in FHIR with a FHIR Maturity level of 2 for the Encounter Resource data elements. FHIR Encounter Resource: https://www.hl7.org/fhir/encounter.html ONC Interoperability Standards Advisory (ISA) - Sending Health Care Survey Information to Public Health Agencies. NHCS in ISA: https://www.healthit.gov/isa/sending-health-care-survey-information-public-health-agencies ONC Interoperability Standards Advisory (ISA) - Reporting Birth and Fetal Death to Public Health Agencies. BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies Promoting Interoperability Programs Eligible Hospitals and Critical Access Hospitals are required to, and Merit-based Incentive Payment System (MIPS) participants may optionally, report on any two measures under the Public Health and Clinical Data Exchange objective of these programs. The § 170.315(f)(5) – Transmission to public health agencies – electronic case reporting certification criteria in the 2015 Edition Final Rule and the ONC Cures Act Final Rule, the § 170.315(f)(7) – Transmission to public health agencies – health care surveys, and the § 170.315 (f)(4) – Transmission to Cancer Registries are three such options to meet these measures. Certified Health IT Product List: https://chpl.healthit.gov/#/search CHPL Cancer: Cancer: https://chpl.healthit.gov/#/search: 170.315 (f)(4): Transmission to Cancer Registries Retired | 170.314 (f)(5): Optional - ambulatory setting only - cancer case information Retired | 170.314 (f)(6): Optional - ambulatory setting only - transmission to cancer registries) The current standard for § 170.315(f)(5), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7® CDA® R2 Implementation Guide: Public Health Case Report, Release 2: the Electronic Initial Case Report (eICR), Release 1, STU Release 1.1. ONC’s Certified Health IT Product List (CHPL) lists 73 EHR or HIT Module products certified to (f)(5) using this standard. eCR IG: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 The current standard for § 170.315(f)(7), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7® CDA® R2 Implementation Guide: National Health Care Surveys (NHCS), R1 DSTU Release 1.2 - US Realm. ONC’s Certified Health IT Product List (CHPL) lists 116 EHR or HIT Module products certified to (f)(5) using this standard. NHCS IG: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=385 The current standard for § 170.315 (f)(4), as listed in ONC’s 2020 Interoperability Standards Advisory Reference Edition, is HL7 CDA® R2 IG: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, R1, DSTU Release 1.1 - US Realm. ONC’s Certified Health IT Product List (CHPL) lists 288 EHR or HIT Module products certified to (f)(4) using this standard. Cancer Reporting IG: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=398 These three widely adopted CDA standards have many of the Encounter data elements contained on this form as Shall (required) or Should (best practice to include if available) conformance criteria, which demonstrates the maturity of these commonly exchanged data elements. In production use: EPIC stork module (obstetrics) for birth reporting. Facility worksheets that collect medical information for live birth and fetal death: https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf. EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement. https://www.hl7.org/fhir/encounter.html NHCS in ISA: https://www.healthit.gov/isa/sending-health-care-survey-information-public-health-agencies BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public- |
| Number of organizations/individuals with which this data element has been electronically exchanged | 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 |
Level 2 – exchanged between 4 or more different EHR/HIT systems. More routinely exchanged between multiple different systems can justify adding to next draft version. Several cancer registries have received cancer reports from at least one provider (per internal technical and programmatic documentation) that include these data elements: Encounter period, Encounter participant type, Primary participant responsible for encounter, Encounter participant individual, Encounter primary performer NPI, Encounter primary performer name, Encounter location address. HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 - US Realm - the Electronic Initial Case Report (eICR) is currently implemented in 5,400+ reporting sites nationally and exchanges Encounter information including: Classification of Patient Encounter, Encounter type, Encounter subject, Encounter Participant Type, Encounter Participant Individual, Participant Overseeing the Encounter, Encounter Primary Performer NPI, Encounter Primary Performer Name, Encounter Primary Performer Professional Role, Encounter Location Address, Reason for Visit, Hospital Encounter Discharge Disposition. HL7 CDA® R2 Implementation Guide: Public Health Case Report, Release 2 - US Realm - the Electronic Initial Case Report (eICR): https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 In production use: EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement As part of Cancer Reporting CDA IGs: IHE Connectathons 2010-2020. HIMSS Interoperability Showcase 2010-19 Public Health Informatics Conference Interoperability Showcase 2014, 2016, 2018 NACCHO 360X Interoperability Demonstrations, 2020 As part of National Health Care Surveys CDA IGs: IHE Connectathons 2019-2020 IHE Connectathon integration profiles for Birth and Fetal Death Reporting - Enhanced (2013 - 2020). IHE Connectathons: Found in 'New Search', filter by 'Select an integration profile = Birth and Fetal Death Reporting-Enhanced' https://connectathon-results.ihe.net/view_result.php?rows=company&columns=actor&title=integration_profile HL7 FHIR Connectathon results (Sept 2020): birth and fetal death reporting results testing between electronic birth registration system vendors (FHIR). FHIR Connectathons: https://confluence.hl7.org/display/FHIR/2020-09+Public+Health+Track HIMSS Interoperability showcase BFDR-E (2018 – 2019) NACCHO 360X Interoperability Demonstrations for Birth and Fetal Death reporting 2020 between NextGen and two state electronic birth registrations system vendors using FHIR. https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 EPIC stork module (obstetrics) for birth reporting: h |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | None |
| Restrictions on Use (e.g. licensing, user fees) | None |
| Privacy and Security Concerns | None |
| Estimate of Overall Burden | Low. EHRs use encounters as a fundamental organizing structure so this set of encounter data elements are already "baked in" to EHRs used by providers. Providers and EHR products will experience no burden for something they already use widely other than EHR companies extending the availability of these data elements to USCDI data sets. Several existing IGs, as listed, require the exchange of this data element. The Promoting Interoperability Programs Objective 8 - Public Health and Clinical Data Registry Reporting, measures 3 -: Electronic Case Reporting and 4: Public Health Registry Reporting require these data elements. Encounter information is routinely communicated in HL7 CDA Documents and some FHIR API transactions. |
| Other Implementation Challenges | None |
Information related to interactions between healthcare providers and a patient.
Data Element |
Information from the submission form |
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| Encounter Participant Time Period |
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