| Submitted By: Grace Cordovano / Enlightening Results | |
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| Data Element Information | |
| Use Case Description(s) | |
| Use Case Description | Under HIPAA's Right of Access (45 CFR § 164.524 https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html), individuals have a right to access PHI in a “designated record set, where the designated record set is defined as a group of records maintained by or for a covered entity comprising: 1) Medical records and billing records about individuals maintained by or for a covered health care provider; 2) Enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or 3) Other records that are used, in whole or in part, by or for the covered entity to make decisions about individuals. Clinical decision support systems (CDSS) and AI-assisted decision-making have become more integrated into patient care, medicine, and healthcare due to Meaningful Use. If CDSS and AI-assisted decision-making may be used to guide patient care, patients should have a right to a copy of the information used to guide their care. This is especially important for continuity of care, for when patients are denied care, treatments, procedures (either by their payor or clinical care team). Patients should have a right to a copy of any CDS data that is generated and used to guide their clinical care, from a right of access standpoint as well as from the point of transparency. |
| Estimated number of stakeholders capturing, accessing using or exchanging | Unknown |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | SNOMED CT https://confluence.ihtsdotools.org/display/DOCCDS/1.+Introduction |
| Additional Specifications | https://www.hl7.org/implement/standards/product_brief.cfm?product_id=334 https://www.healthit.gov/isa/sharable-clinical-decision-support |
| Current Use | In limited use in production environments |
| Supporting Artifacts |
https://www.healthit.gov/isa/sharable-clinical-decision-support |
| Number of organizations/individuals with which this data element has been electronically exchanged | N/A |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | Unknown |
| Restrictions on Use (e.g. licensing, user fees) | Unknown |
| Privacy and Security Concerns | The privacy and security concerns about this data element is not unique to this particular type of PHI, thus covered by HIPAA and other governance. |
| Estimate of Overall Burden | Unknown |
| Other Implementation Challenges | Unknown |
| 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 | Comment Level - May 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 |
Comment