|Submitted By: Holly Miller, MD / MedAllies|
|Data Element Information|
|Use Case Description(s)|
|Use Case Description||We are proposing “Assessment” as a USCDI data class to serve as a repository for any standardized assessment instrument. There are thousands of assessment instruments in use across clinical settings, public health providers, payors, and researchers.
As one example, the CMS Data Element Library (DEL: Home - Data Element Library (cms.gov)) is an example of multiple standardized data elements used in the federally mandated assessment instruments by LTPAC (Long-Term and Post-Acute Care) providers who collectively provide care to over 7 million Medicare Beneficiaries per year. Because these assessments are required for payment and quality reporting, they are collected by the more than 15,000 Skilled Nursing Facilities (SNFs), 11,000 Home Health Agencies (HHAs), 4,600 Hospice Care agencies, 1,100 Inpatient Rehabilitation Facilities (IRFs), and 400 Long-Term Care Hospitals (LTCHs). These standardized data are collected and submitted to CMS as required by these entities. Most of these data elements are mapped to LOINC and some are mapped to C-CDA templates.
The DEL incorporates only a tiny percentage of standardized assessments currently in use; and the use of standardized assessments is universal in health care.
|Estimated number of stakeholders capturing, accessing using or exchanging||This data class pertains to most or all patients, providers or requestors.|
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||LOINC, SNOMED-CT
|Current Use||This data element has been used at scale between multiple different production environments to support the majority of anticipated 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.|
|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||This would vary depending on the specific assessment instrument and how it is used.|
|Other Implementation Challenges||Unknown|
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use)
Applicable Vocabulary Standard(s)