|Submitted By: Nedra Garrett / Centers for Disease Control and Prevention|
|Data Element Information|
|Use Case Description(s)|
|Use Case Description||"Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to 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 new innovations and more rapid disease detection. Clinical notes are important for public health and research uses to ""get the whole story"" that structured EHR text entry cannot always provide.
The eight note types in USCDI V1 were a good start to capturing the most common clinal notes exchanged but the National Health Care Surveys have identified Summarization of encounter note narrative, Initial evaluation note and Outpatient note as three types of ambulatory notes as both commonly exchanged and important to data collection for the National Ambulatory Medical Care Survey.
|Estimated number of stakeholders capturing, accessing using or exchanging||Approximately 620,000 physicians in the US are active and have at least some component of ambulatory practice and thus are annually eligible for sampling and recruitment into the National Ambulatory Medical Care Survey (NAMCS), one of the two Health Care Surveys in the MedMorph Health Care Surveys Use Case. NAMCS, 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.|
|Link to use case project page||https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm|
|Maturity of Use and Technical Specifications for Data Element|
https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/
|Current Use||Extensively used in production environments|
|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.|
|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||If this data is already in the EHR, then the burden to implement should be minimal because it does not require the creation of a new data element or modifying an existing one.|
|Other Implementation Challenges||When using FHIR there may be associated costs with development of tools needed to access specific data. Often these costs may be a limitation for states who need to develop tools to access certain data.|
Represents narrative patient data relevant to the respective note types.
Information from the submission form
|Initial evaluation note||
Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component.