| Submitted By: Swapna Abhyankar / Regenstrief Institute, LOINC Document Ontology Subcommittee | |
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| Data Element Information | |
| Rationale for Separate Consideration | This data element has some overlap with other existing and proposed Clinical Notes data elements because Telehealth is a setting versus a type of service (Consultation, History & Physical, Discharge Summary, Transfer Summary, etc.). For example, Telehealth consultation notes span the “Consultation Note” and “Telehealth Note” data elements. However, we feel it is important to specify this particular setting because the vast majority of LOINC terms representing telehealth notes aren’t captured in the data elements that represent particular types of service and in the midst of the COVID-19 pandemic, clinical care provided by telehealth has become increasingly important. |
| Use Case Description(s) | |
| Use Case Description | The set of proposed data elements are complementary to the existing Clinical Notes data elements in USCDI v1 and together, they better represent the broad scope of clinical documentation that occurs each day in the U.S. Healthcare system. |
| Estimated number of stakeholders capturing, accessing using or exchanging | These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders. |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. https://loinc.org |
| Additional Specifications | There are HL7 C-CDA implementation guides for several of these data elements (Transfer summary, Plan of care, Referral note). In addition, the FHIR DocumentReference and other resources across versions, including the US Core, utilize these data elements. |
| Current Use | Extensively used in production environments |
| Supporting Artifacts |
These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders. |
| 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 |
These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders. |
| 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 | Minimal - already being used |
| ONC Evaluation Details Each submitted Data Element has been evaluated based on the following 4 criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI |
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| Maturity – Standards/Technical Specifications | Level 1/2 - Must be represented by a vocabulary standard or an element of a published technical specification |
| Maturity - Current Use | Level 2 - Used at scale in more than 2 different production environments |
| Maturity - Current Exchange | Level 2 - Demonstrates exchange between 4 or more organizations with different EHR/HIT systems |
| Breadth of Applicability - # Stakeholders Impacted | Level 2 - Used by a majority of patients, providers or events requiring its use |
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