|Submitted By: Dr. Christine Dehlendorf / Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco|
|Data Element Information|
|Use Case Description(s)|
|Use Case Description||Providing individuals at risk of undesired pregnancy access to contraceptive services is an essential component of a quality health care system that optimizes reproductive health and wellness. High rates of unintended pregnancy in the United States indicate that many individuals are not having their needs for pregnancy prevention met. Analyses of the National Survey of Family Growth find that only 46% of women at risk of unintended pregnancy receive contraceptive services in a year, with disparities by both race/ethnicity and age (with younger patients being less likely to receive contraceptive services (1). Improving delivery of contraceptive care to those in need has the potential to improve reproductive outcomes overall and mitigate health disparities. One essential aspect of this care delivery is identifying those in need of contraceptive services. This identification can be facilitated by standardized data elements designed to determine who is in need of services and feed into patient-centered workflows to provide appropriate services.
In considering the use of standardized data elements, it is essential to recognize that the provision of contraception care services has a fraught history in the United States, marked by targeted marketing of birth control to and forced sterilization of Black and Indigenous people of color, as well as poor people and people with disabilities, motivated by the desire to curb the reproduction of these groups (2). Asking about contraception and pregnancy prevention in the healthcare setting carries the weight of this history. It is therefore critical that screening for contraceptive need is done in a manner that does not inadvertently reproduce harm by communicating a sense of expectation or pressure to use pregnancy prevention methods.
Documenting those in need of contraceptive services has the additional benefit of allowing for monitoring of provision on contraceptive care to the population of interest between programs and over time. There are numerous state- and federal-level contraceptive access programs currently operating in the U.S. These programs rely on agency-level data from EHRs to analyze the extent to which participating healthcare agencies are meeting patients’ reproductive health needs and implementing best-in-class contraceptive care workflows.
The Person-Centered Reproductive Health Program at UCSF has developed, in consultation with race equity and Reproductive Justice leaders, a screening tool to determine whether a patient would like contraceptive care services in that day’s visit. This tool, the self-identified need for contraceptive care, consists of a primary question, “Do you want to talk about contraception or pregnancy prevention during your visit today,” and follow-up prompt (3). This screening tool has been embedded and tested in EHRs and has a LOINC code, yet it is not included in USCDI.
The SINC screening question is as follows:
We ask everyone about their reproductive health needs. Do you want to talk about contraception or pregnancy prevention during your visit today?
If yes: Mark yes and ensure appropriate counseling is provided
If no: Clarification Prompt: There are a lot of reasons why a person wouldn't want to talk about this, and you don't have to share anything you don't want to. Do any of these apply to you? (mark all that apply)
I’m here for something else
This question does not apply to me
I prefer not to answer
I am already using contraception (and what)
I am unsure or don’t want to use contraception
I am hoping to become pregnant in the near future
This question is intended to be added to the electronic health record and integrated as part of routine care and screening. Throughout the development of this question and the response options, attention was paid to ensure that people’s own preferences and needs related to reproduction are recognized and respected. For example, by initiating the screening with a reference to the standardized nature of the question, we sought to prevent any perceived, or real, targeting of the reproductive choices of certain individuals or individuals from certain groups. We also carefully considered the ordering of the answer options so as not to infer that the most acceptable response was “I am already using contraception”. Implementation of this screening is designed to support reproductive autonomy and patient privacy, and decrease inequities in the provision of contraception services.
In addition to supporting patient-centered workflows for contraceptive provision, the question detailed above is designed to be used to define the denominator for an electronic Clinical Quality Measure of contraceptive provision and use, with the goal of identifying the extent to which facilities and clinics are meeting the needs for contraceptive services of their patient population in need of these services.
Guidance for Implementing the SINC:
This question can be asked either by a provider OR by the person who screens patients before seeing the provider (medical assistant, health educator, nurse, etc.) to assess for desired services.
Screen patients ages 18-44 once a year.
There may be patients for whom the question is not relevant (e.g. they get their care elsewhere, they have had a hysterectomy, they only have sex with individuals who do not produce sperm, or they simply do not want to be asked). For these patients, it is important to ensure that this information is noted in a way that ensures that they are not asked the question unnecessarily.
For individuals who indicate they do not wish to discuss contraception because they are at the clinic for another reason, clinics can develop workflows to facilitate this question being asked at a follow-up visit.
2) These dynamics have been extensively documented by many authors, including Dorothy Roberts’ Killing the Black Body and Harriet Washington’s Medical Apartheid. For contemporary examples of contraceptive coercion, forced sterilization, and implicit bias in contraceptive counseling, see authors Anu Gomez, A.M. Stern, and Christine Dehlendorf
|Estimated number of stakeholders capturing, accessing using or exchanging||SINC is intended for use in primary care settings to improve access to patient-centered contraceptive care. Entities interested in collecting or exchanging data related to contraceptive care quality improvement are stakeholders. Currently, there are a number of family planning and reproductive health quality improvement initiatives and programs that could leverage these data elements, if included in USCDI. Two key initiatives that could utilize these data elements imminently are the federal Title X Family Planning Program and Upstream USA.
Title X has included SINC as an optional data element in its encounter-level data reporting requirement (1) . Title X aims to collect this data element via interoperability standards by 2025. Title X serves between 1.5-4 million patients of reproductive age per year through approximately 100 grantee organizations.
Upstream USA is a nonprofit working to reduce unintended pregnancy by expanding access to contraception. Upstream currently collects these data elements via two data aggregation vendors that use proprietary software as well as interoperability standards (CCD). Upstream is exploring opportunities to collect these data via FHIR, state HIEs, and other options. Upstream has a goal of partnering agencies that serve one million female patients of reproductive age per year by 2024 (2).
UCSF is also working with the National Association of Community Health Centers to implement SINC in community health centers across the country. As Community Health Centers are the primary medical home for over 30 million people in more than 13,000 rural and urban communities, there is the potential for widespread adoption.
|Link to use case project page||https://opa.hhs.gov/research-evaluation/title-x-services-research/family-planning-annual-report/fpar2|
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||Self-Identified Need for Contraception (SINC) LOINC: 98076-3
Example answer list:
Yes (qualifier value) LA33-6
No - I do not want to talk about contraception today because I am here for something else; LA32389-1
No - This question does not apply to me/I prefer not to answer; LA32390-9
No - I am already using contraception; LA32393-3
No - I am unsure or don't want to use contraception; LA32391-7
No - I am hoping to become pregnant in the near future; LA32392-5
|Current Use||In limited use in test environments only|
SINC does not yet have technical specifications, other than the above referenced implementation guide. SINC is also included in FPAR 2.0 as an optional data element. The eCQM that uses SINC to define the denominator will be submitted for endorsement by the National Quality Forum in early 2022.
|Number of organizations/individuals with which this data element has been electronically exchanged||N/A|
|Restrictions on Standardization (e.g. proprietary code)||The SINC is stewarded by UCSF and is not proprietary (https://pcrhp.ucsf.edu/sinc ).|
|Restrictions on Use (e.g. licensing, user fees)||No known restrictions on using SINC.|
|Privacy and Security Concerns||No known privacy and security concerns above and beyond the normal requirements to ensure that data elements are shared only with entities that have active data use agreements and the infrastructure to securely exchange PHI/PII.|
|Estimate of Overall Burden||UCSF has worked with eight clinics using three different EHR systems (Epic, OCHIN Epic, and AthenaOne). In these instances, changes were able to be implemented in about 3 months in collaboration with clinical and vendor teams. The implementation burden depends on the change process for the EHR at the system. The change process can involve many committee meetings and months. Most systems, from our experience, are able to implement the EHR template changes in about 3 months.
How hard is it to access and provide the data?
The primary burden of implementing SINC depends on the change processes involved to embed the SINC into the relevant EHR template so that care teams can use the data element. SINC must also become part of the regular workflow in primary care for patients of reproductive age.
Is it only available in an outside system, such as a lab reporting system?
The data element would reside within the clinical agency’s EHR system server.
Does it need to be calculated by the patient or provider, or can it be automatically retrieved or calculated by the system in a production environment?
The data element could be automatically retrieved and summarized within the production environment or relevant external stakeholder that receives the data.
Does it require significant time on the part of patient or provider to access or record or does it require an interuption in normal workflow to capture?
UCSF advocates for SINC to be included as part of a patient-centered primary care workflow, enhancing access to reproductive health services for those who need it. Therefore, the added time burden will be offset by enhanced quality of care. The question is estimated to require a minute or less to implement.
Does it require significant developer time to implement in EHR systems?
See above re: primary burden.
|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
|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||Comment Level - Used in limited test environments or pilots|
|Maturity - Current Exchange||Comment Level - Demonstrates limited exchange with external organizations, on same or different EHR/HIT systems|
|Breadth of Applicability - # Stakeholders Impacted||Level 1 - Used by many, but not most, patients, providers or events requiring its use|