| Submitted By: TICIA Louise GERBER / Health Level Seven International | |
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| Data Element Information | |
| Use Case Description(s) | |
| Use Case Description | If patients or caregivers could see flowsheet data such as obstetric information and medication administration data, they could catch errors and improve safety. It will also empower patients to study and trend their data. It would also be useful to provider facing applications that could provide clinical decision support that improves patient care. For example, a clinical decision support tool could track the values entered by clinicians and generate appropriate alerting when anomalies are auto-detected. Flowsheet data is also useful for informatics interventional research that employ targeted patient and provider facing technology and study the impact. While some information from flowsheets may appear in narrative in the notes, it is more useful computationally if in structured observation form. We are proposing a few flowsheets but see this data class growing in the future to include additional elements such as cancer staging information since there are many structured data sets captured in flowsheets in the EHR that would be of value to expose in the USCDI. |
| Estimated number of stakeholders capturing, accessing using or exchanging | Flowsheets have been used in medicine since practices and hospitals were on paper. This paper shows how many observations were captured: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961798/ |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | LOINC has codes for flowsheet elements/structured clinical data including for prenatal, cancer staging, and medication administration (clinical LOINC), FHIR R4 Observation resource, MedicationAdministration, among others, can be used to communicate the information. www.hl7.org/fhir/ https://loinc.org/ |
| Additional Specifications | N/A |
| Current Use | Extensively used in production environments |
| Supporting Artifacts |
Most EHRs capture structured data in flowsheets including discrete data for obstetrics and records of medication administration. |
| Number of organizations/individuals with which this data element has been electronically exchanged | 2-3 |
| Supporting Artifacts |
This answer to this question is uncertain. Exchange is limited by its lack of inclusion in USCDI. We would expect that most sharing today is highly implementation specific. This data is not easily accessible electronically for patients. |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | None known. |
| Restrictions on Use (e.g. licensing, user fees) | None known. |
| Privacy and Security Concerns | None known. |
| Estimate of Overall Burden | No notable burden to implement. |
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data Element |
Information from the submission form |
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| Medication Administrations Report (Flowsheet) |
Description
Structured data captured in a Medication Administration Report (usually for inpatients) showing each drug administered, who administered it, what time it was administered, etc.
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