Provider-authored directive for the delivery of patient care services.

Data Element
Portable Medical Orders
Description

Orders for certain aspects of medical care, including end-of-life care, which support a transfer of care request from one practitioner or organization to another that provides end-of-life or life-sustaining care services. Different types of portable medical orders are used in different jurisdictions.
Submitted By: Grace Glennon on behalf of Joel Andress and CMS-CCSQ / On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Rationale for Separate Consideration A data element encompassing orders for all services (Types of orders for medical care/services ) is a Level 2 element, but we believe a data element specifically for end of life care orders should be included, due to the high priority nature of these specific orders, and the USCDI taskforce recommendation to prioritize the concept. Additionally, the COVID-19 pandemic has renewed the push for an expansion of end of life care services with thousands of Americans suffering from long-term, debilitating symptoms. End of life care, like palliative care, has also been associated with a higher quality of life and better pain management in patients who have received these services.

https://www.healthit.gov/sites/default/files/facas/2021-04-15_USCDI_Task_Force_Recommendations_508.pdf
https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/04/20/long-haul-covid-renews-push-to-expand-palliative-care
https://www.who.int/news-room/fact-sheets/detail/palliative-care
Use Case Description(s)
Use Case Description Portable Medical Orders, including orders (service requests) for end of life care services are used extensively by hospitals, clinicians and providers, and are included in CMS quality measurement. They are important for quality improvement, clinical decision support, and measurement to ensure proper patient populations are provided the proper end of life care as needed. These data are necessary to confirm appropriate and high quality of care is received for patients across different populations. It is clinically relevant from a care perspective and a quality measurement perspective.

Currently, CMS quality eCQMs include the order concepts for end of life care services, including hospice, comfort care, palliative care.
Estimate the breadth of applicability of the use case(s) for this data element More than 4,000 hospitals and 1 million providers currently capture, access and exchange this order (service request) information. This information is currently electronically submitted by providers and hospitals to CMS for quality measurement.
Link to use case project page https://ecqi.healthit.gov/ecqms :eCQI resource center, includes measure specifications for CMS program eCQMs (i.e. CMS 69, CMS 347, CMS 506, CMS 159)
Use Case Description Each step in the chain of events between a clinicians request for an end of life care service (order) and the completion of that service is critical for vigilance and surveillance of patient safety and appropriate care. It is important to have the capacity to evaluate the clinicians intent and the actual completion across care settings and across time. Specifically, this concept supports care coordination by allowing for transfer of information of the order to be completed if the service is not being provided by the same organization.
Estimate the breadth of applicability of the use case(s) for this data element All healthcare providers and hospitals using EHR systems should have order information for end of life care services documented and accessible.
Link to use case project page https://ecqi.healthit.gov/ecqms
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) SNOMED CT
ICD-10
CPT

Examples:
Comfort Measures SNOMED CT Value set: 1.3.6.1.4.1.33895.1.3.0.45
Hospice Care Ambulatory Value set: 2.16.840.1.113883.3.526.3.1584
ICD-10 Encounter for palliative care: Z51.5
HL7 Service Type value set: https://www.hl7.org/fhir/valueset-service-type.html
https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
Additional Specifications HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request Profile: http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-servicerequest.html

US CORE Implementation Guide: Service Request noted as a future profile under consideration: https://www.hl7.org/fhir/us/core/future-of-us-core.html

HL7 FHIR ValueSet Service Type: Includes hospice care, palliative medicine (https://www.hl7.org/fhir/valueset-service-type.html)

HL7 FHIR Quality Measure STU2 for FHIR R4 Implementation Guide, Library-Hospice (http://hl7.org/fhir/us/cqfmeasures/Library-Hospice.html)
Current Use Extensively used in production environments
Supporting Artifacts Orders (service requests) for end of life care services are routinely captured in EHR systems used by hospitals and providers for the use in CMS quality reporting eCQMs across programs including IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of order (service request) related data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes orders (service requests) for an intervention (i.e. palliative care, hospice, comfort care).
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs ; https://ecqi.healthit.gov/ecqms
Extent of exchange 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 End of life care orders (service requests) data for quality measurement is electronically exchanged from organization’s EHR systems to CMS for reporting and payment quality measurement programs, via QRDA files and other architectures. These orders (service requests) data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
https://ecqi.healthit.gov/qrda; https://confluence.hl7.org/display/FHIR/2021-09+Clinical+Reasoning
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No challenges anticipated. These data are available in standard terminology that can be publicly access via the VSAC and HL7.
Restrictions on Use (e.g. licensing, user fees) We are not aware of any restrictions.
Privacy and Security Concerns These data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data element.
Estimate of Overall Burden Orders (Service requests) for end of life care are regularly captured by a broad range of healthcare providers, and should not cause burden to implement. Some burden required to include a ServiceRequest profile as a US Core profile, though it is already noted as a potential addition for future iterations, and built out in QI Core.
Other Implementation Challenges N/A
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following 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
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by yale-coredQMRoadmap on

CMS-CCSQ/CDC Joint for Orders for End of Life Care for USCDI v5

CMS-CCSQ recommends this Level 2 data element be added to USCDI v5. Orders for End of Life Care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life and is yet to be represented in USCDI. These data are routinely captured in EHR systems and need to be interoperable and exchangeable to reduce discordance between care provided and patient wishes, and to enhance value of care at end of life. This critical information is required to support a transfer of care request from one practitioner or organization to another that provides end-of-life care services. This data element was previously identified as a joint CMS-CDC priority and supports advancing patient care quality.

Submitted by yale-coredQMRoadmap on

Cntd. CMS-CCSQ Support for Orders for End of Life Care for v4

Orders for end of life care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life and is yet to be represented in USCDI. These data need to be interoperable and exchangeable to reduce discordance between care provided and patient wishes, and to enhance value of care at end of life. This data element continues to be a joint CMS-CDC priority and supports advancing patient care quality, which aligns with the purpose of the USCDI (setting a foundation for broader sharing of electronic health information to support patient care).

Maturity: ONC recently advanced this data element to Level 2 based on maturity of standards.

  • Current standards:
    • Newly added—HL7 FHIR US CORE Implementation Guide STU 5, Service Request Profile (http://hl7.org/fhir/us/core/StructureDefinition-us-core-servicerequest.html)
    • HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request Profile (HL7.FHIR.US.QICORE\QICoreServiceRequest - FHIR v4.0.1)
    • Concepts captured in mature terminology: LOINC, Systematized Nomenclature of Medicine (SNOMED)
  • Current uses, exchange, and use cases: Orders (service requests) for end of life care services are routinely captured in EHR systems used by hospitals and providers and are used in CMS quality reporting eCQMs across programs. The relevant information required to support a transfer of care request from one practitioner or organization to another that provides end of life care services is critical.

Submitted by HCapon on

PACIO Project Comments on Orders for End of Life Care

  • Data Class: Orders (Level 2) 

  • Data Element: Orders for End of Life Care (Level 2) 

  • Recommendation: Change the name of the data element “Orders for End of Life Care” to “Portable Medical Orders”.   

  • Rationale: Conceptually, including data elements for Orders for End of Life Care and Portable Medical Orders for Life-Sustaining Treatment is in the USCDI duplicative. We have found jurisdictions that utilize Portable Medical Orders during encounters that are NOT related to EOL care. In Maryland, for example, a Medical Order for Life-Sustaining Treatment (MOLST) should be prepared for all clinical encounters with an adult, regardless of health status. We propose the data element, “Orders for End of Life Care” be renamed "Portable Medical Orders" to expand the application of this concept for all US jurisdictions. There is currently a data element entitled, “Portable Medical Orders for Life-Sustaining Treatment” under the Orders data class in the USCDI Comment Level. Therefore, we recommend inclusion of one of these data elements in the USCDI V4, but suggest the name of the data element included should be Portable Medical Orders for Life-Sustaining Treatment, in order to encompass a broader range of clinical encounters. 

Submitted by HCapon on

PACIO Project Support to Advance Orders for End of Life Care

  • Data Class: Orders (Level 2) 

  • Data Element: Orders for End of Life Care (Level 2) 

  • Recommendation: Include the “Orders” data class and “Orders for End of Life Care” as a data element under that class in USCDI V4. 

  • Rationale: The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. The PACIO Community believes the data elements Care Experience Preferences, Treatment Preferences, End of Life Orders and Durable Medical Power of Attorney included together provide the most essential information to give a holistic view of the individual’s wishes, necessary to inform care. The PACIO Community appreciates that the Care Experience Preference, Advance Directive Observation, and Treatment Intervention Preferences data elements are planned for the Goal data class in V4, but to maximize the clinical utility this information we recommend also advancing Orders for End of Life Care as data element in V4. As stated previously, we understand expanding these concepts beyond advance healthcare decision documents to a more broad utilization than our use case which we have no objection to. 

Submitted by PACIO-Project on

PACIO Support to Advance Orders for End of Life Care

Advance the “Orders for End of Life Care” data element under the Order data class to USCDI v4.  It is recognized that the previous concept of “Portable Medical Orders for Life-Sustaining Treatments” was too narrowly focused and additional practitioner-authored orders related to goals of care and specific medical treatments or interventions should be included. These orders for end of life care are established by a practitioner regarding treatments that restore, sustain, or prolong a patient’s life. These types of medical orders are intended to be consistent with the patient’s instructions and wishes.

The PACIO Community strongly recommends this data element be promoted to USCDI V4.

Submitted by Svellanky on

CMS-CCSQ Support for Orders for End of Life Care for USCDI v4

Orders for end-of-life care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life and is yet to be represented in USCDI. These data need to be interoperable and exchangeable to reduce discordance between care provided and patient wishes, and to enhance value of care at end of life. This data element was previously identified as a joint CMS-CDC priority and supports advancing patient care quality, which aligns with the purpose of the USCDI (setting a foundation for broader sharing of electronic health information to support patient care).

Maturity: ONC recently advanced this data element to Level 2 based on maturity of standards.

Current uses, exchange, and use cases: Orders (service requests) for end-of-life care services are routinely captured in EHR systems used by hospitals and providers and are used in CMS quality reporting eCQMs across programs. The information is important for quality improvement, clinical decision support, and care coordination to ensure patients are provided the proper end-of-life care as needed. The relevant information required to support a transfer of care request from one practitioner or organization to another that provides end-of-life care services is critical.

Submitted by Lynda S Hoeksema on

PACIO update re Level 1 Orders for End of Life Care Data Element

The PACIO Community (Post-Acute Care Interoperability) leadership wishes to update the ONC/USCDI with current efforts relating to the concept of Advance Directives and portable clinician authored orders in that domain. The PACIO Community continues to test FHIR interoperability of Advance Directive Information (ADI) during HL7 and CMS Connectathons (September 2021, May 2022, and July 2022) and resolve HL7 balloting comments in preparation for publication in upcoming months of a FHIR based Advance Directive Information Implementation Guide (IG) as Standard for Trial Use-1 (STU1).  As part of the work, PACIO completed an environmental scan across states and other jurisdictions to inform a design that could work on a national level while allowing for jurisdictional differences. PACIO’s focus has been on “model of meaning” of ADI concepts as opposed to “model of use” where only specific narrative or forms are used. A benefit of exchanging semantic meaning recognizes the current reality of diverse state and local jurisdictional processes present as the nation moves towards standards-based data exchange. The PACIO ADI Community has been working with external national organizations on the concept of practitioner authored information and orders that includes all types of advance directive concepts, including during emergency situations, end of life situations, and whenever an individual is unable to express for themselves their wishes and desires. The PACIO Community is working with external stakeholders both within the interoperability and clinical ecosystems to tease out how the concepts of clinician/practitioner authored orders (including portable non-location-based orders) in the domain of “Advance Directive” would differ from other “Types of orders for medical care/services” as currently in USCDI level 2 and/or “Orders for End-of-Life Care” in USCDI Level 1.

Submitted by nedragarrett_CDC on

CDC-CMS Joint Priority Data Element

 Both CDC and CMS support inclusion of this element in v3. More details are provided in the joint letter sent to ONC. 

Submitted by sg999 on

CMS-CCSQ Support for Orders for End-of-Life Care

CMS-CCSQ continues to advocate for orders for end-of-life care (comfort care, palliative care, hospice) to be reclassified to Level 2.

Orders for end-of-life care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life. This data needs to be interoperable and shareable to reduce discordance between care provided and patient wishes and enhance value of care at end of life. This element represents a priority data concept that is not yet represented in USCDI and must be prioritized.

Maturity:

  • Current standards:
    • Orders can be exchanged in mature FHIR standards, including Service Request profile in the QI Core IG
    • End-of-Life Care concepts are captured in mature terminology: LOINC, SNOMED
  • Current uses, exchange, and use cases: Orders (service requests) for end-of-life care services are routinely captured in EHR systems used by hospitals and providers and are used in CMS quality reporting eCQMs across programs including IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of order (service request) related data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes orders (service requests) for an intervention (i.e., palliative care, hospice, comfort care).

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