Data Element

Information from the submission form
Conditions with substantial risk of complications ICD 10, SNOMED
Description

Serious chronic mental illness
Transplants
Substance Use Disorder
Incontinence
Healed pressure injury
Active pressure injury

Submitted By: Holly Miller, MD / MedAllies
Data Element Information
Use Case Description(s)
Use Case Description Use Case
These are data elements required to improve the safety of handoffs when clinical care responsibilities are passed to another care team member or care team either temporarily or permanently. Examples include hand offs at change of shift and permanent transitions of care to another care team or site of care. Handoffs occur in every health care setting and are a requirement whenever 24-hour care is provided, or care is provided intermittently in the patient’s home. This includes hospitals, LTPAC facilities, homes, and prisons. Although most handoffs occur between care providers using a common EHR/HIT system, many transitions of care from one site to another require exchange to occur between two different EHR/HIT systems. Even when handoffs occur within a single EHR system ease of access to these Special Alerts will significantly help to prevent medical errors and reduce the risk of injuries and harm.
Estimated number of stakeholders capturing, accessing using or exchanging Estimate number of stakeholders
All providers of clinical care in 24-hour and home care settings will use these data elements at the beginning and at the end of their shifts. All providers of clinical care that receive patients in transfer from another site or team will use these data elements. This encompasses most providers.
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) ICD 10, SNOMED, LOINC, RxNorm
Additional Specifications N/A
Current Use Extensively used in production environments
Supporting Artifacts These data elements are nearly universally captured in existing EHR systems but are not grouped and escalated to be readily utilized for patient care.
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.
Potential Challenges
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 The burden for collection is minimal given these observations are already collected in the EHR. The burden is to ensure that these data elements are captured and escalated to the alert level within an EHR system when they are applicable.
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 Comment Level - Used by few stakeholders, or for narrowly defined conditions or events
Evaluation Comment This data element represents a subset of the data elements Problems and Encounter Diagnosis, thus a narrower breadth of applicability.

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