|Submitted By: Leslie Kelly Hall / Engaging Patient Strategy|
|Data Element Information|
|Rationale for Separate Consideration||Very high benefit and low risk. Known LOINC codes and current work flows and exchange in place. https://loinc.org/LG38755-1/|
|Use Case Description(s)|
|Use Case Description||Consistent with Clinical notes, view download and transport and the desires of information sharing, OP notes is a necessary component for access and|
|Estimated number of stakeholders capturing, accessing using or exchanging||Approximately 51% of all hospital visits under Medicare include a procedure that includes an operative note. Cancer patients and their supporting clinical team members, count on OP notes for continuity of care and transitions.|
|Maturity of Use and Technical Specifications for Data Element|
|Current Use||This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders|
Every EMR contains an OP note for every operative procedure.
|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.|
This is commonly collected but not specifically called out in USCDI.
As a patient advocate, I do not have access to the artifacts.
|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||Very little burden. Codes, creation, storage and standards are in place.|
|Other Implementation Challenges||none|
|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||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|