| Interoperability Standards Advisory (ISA)

Data Element

Information from the submission form

Types of orders for medical care/services

Description

Order or a Service Request represents a request for a procedure, diagnostic service, intervention, laboratory test, follow-up care, or other planned service for a patient. This concept may be used to share relevant information required to support a referral or a transfer of care request from one practitioner or organization to another when a patient is required to be referred to another provider for a consultation /second opinion and/or for short term or longer-term management of one or more health issues or problems.

Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Rationale for Separate Consideration	USCDIv1 includes medical services that are complete (procedures, labs) and Plan of Treatment, but not orders for services. Services not provided by the same organization where ordered requires a transfer of a patient with the relevant order information.
Use Case Description(s)
Use Case Description	Orders (service requests) are used extensively by hospitals, clinicians and providers as part of the quality measurement. They are important for quality improvement, clinical decision support and measurement to understand the link between things ordered and then completed/administered. These data are necessary to confirm appropriate and high quality of care is received for patients across different populations. It is clinically relevant from a care perspective and a quality measurement perspective to distinguish information about services orders, and those completed. Currently, CMS quality measures include the following order concepts. Orders for: • Labs and diagnostic studies • Interventions (i.e. hospice, comfort care, palliative care) and procedures • Devices • Follow-ups/referrals
Estimated number of stakeholders capturing, accessing using or exchanging	More than 4,00 hospitals and 1 million providers currently capture, access and exchange this order (service request) information. This information is currently electronically submitted by providers and hospitals to CMS for quality measurement. eCQI resource center, includes measure specifications for CMS program eCQMs (i.e. CMS 125, CMS 71, CMS 645): https://ecqi.healthit.gov/ecqms
Link to use case project page	https://ecqi.healthit.gov/ecqms
Use Case Description	Each step in the chain of events between a clinician’s request for a service (order) and the completion of that service is critical for vigilance and surveillance of patient safety and appropriate care. It is important to have the capacity to evaluate the clinician’s intent, the actual completion across care settings and across time. Specifically, this concept allows for transfer of information of the order to be completed, if the service is not being provided by the same organization.
Estimated number of stakeholders capturing, accessing using or exchanging	All healthcare providers, laboratories, hospitals using EHR systems should have order information documented and accessible.
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)	Orders reference services available in standardized terminology: Intervention order (Comfort measures): SNOMEDCT Device order: SNOMEDCT Diagnostic study, laboratory test order: LOINC Encounter/follow-up order: SNOMEDCT https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
Additional Specifications	HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request: http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-servicerequest.html CMS Quality Data Model (QDM) version 5.5 Guidance, orders (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf) US CORE Implementation Guide: Service Request noted as a future potential profile: https://www.hl7.org/fhir/us/core/future-of-us-core.html
Current Use	Extensively used in production environments
Supporting Artifacts	Orders (service requests) are routinely captured in EHR systems used by hospitals and providers for the use in CMS quality reporting eCQMs across programs including IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of order (service request) related data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes order (service requests) for a procedure, diagnostic service, intervention, laboratory test, or other planned service for a patient. 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
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	Orders (service requests) 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 architectures. These orders (service requests data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons. https://ecqi.healthit.gov/qrda 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 element.
Estimate of Overall Burden	Orders (Service requests) are regularly captured by a broad range of healthcare providers, and should not cause burden to implement. Some burden required to include a ServiceRequest profile as a US Core profile, though it is already noted as a potential addition for future iterations, and built out in QI Core.
Other Implementation Challenges	N/A

Comment

Submitted by nedragarrett_CDC on 2022-09-28

CDC-CMS Joint Priority Data Element for USCDI v4

CDC continues to recommend inclusion of this high priority data element in USCDI v4. This element is also shared high priority item for CMS/CDC as outlined in our joint letter

Submitted by Lynda S Hoeksema on 2022-04-29

PACIO update re: Level 2 data element Types of Orders

The PACIO Community (Post-Acute Care Interoperability) leadership wishes to update the ONC/USCDI with current efforts relating to the concept of Advance Directives and portable clinician authored orders in that domain. The PACIO Community continues to test FHIR interoperability of Advance Directive Information (ADI) during HL7 and CMS Connectathons (September 2021, May 2022, and July 2022) and resolve HL7 balloting comments in preparation for publication in upcoming months of a FHIR based Advance Directive Information Implementation Guide (IG) as Standard for Trial Use-1 (STU1). As part of the work, PACIO completed an environmental scan across states and other jurisdictions to inform a design that could work on a national level while allowing for jurisdictional differences. PACIO’s focus has been on “model of meaning” of ADI concepts as opposed to “model of use” where only specific narrative or forms are used. A benefit of exchanging semantic meaning recognizes the current reality of diverse state and local jurisdictional processes present as the nation moves towards standards-based data exchange. The PACIO ADI Community has been working with external national organizations on the concept of practitioner authored information and orders that includes all types of advance directive concepts, including during emergency situations, end of life situations, and whenever an individual is unable to express for themselves their wishes and desires. The PACIO Community is working with external stakeholders both within the interoperability and clinical ecosystems to tease out how the concepts of clinician/practitioner authored orders (including portable non-location-based orders) in the domain of “Advance Directive” would differ from other “Types of orders for medical care/services” as currently in USCDI level 2 and/or “Orders for End-of-Life Care” in USCDI Level 1.

Submitted by nedragarrett_CDC on 2021-09-29