| Submitted By: Rachel Eager / New York eHealth Collaborative | |
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| Data Element Information | |
| Rationale for Separate Consideration | Provenance is a data class in USCDI however in longitudinal CCDs it is difficult to tell if the procedure was self-reported or performed during that visit. Procedure provenance will add another layer of information to the procedure section. |
| Use Case Description(s) | |
| Use Case Description | When CCDs are combined into a longitudinal CCD it is difficult to tell if a provider is recording a patient’s past procedure in the procedure section or this procedure happened at the time of the visit. If procedure provenance was added as a data element this gives providers looking at a longitudinal CCD more information about whether that procedure was self-reported or happened in that episode of care. This is especially important when this data is being exchanged across many different providers caring for a patient. |
| Estimated number of stakeholders capturing, accessing using or exchanging | This would be a level 2 element that would pertain to any patient that has ever received a procedure. |
| Use Case Description | If a patient has self-reported having a procedure in the past this may have been filled out in the procedure section but the patient may have not necessarily gotten that specific procedure. Procedure provenance helps to define this by allowing the provider to categorize this information as self-reported. In other cases, where the procedure is actually completed during the visit this gives another layer of information to the health history of a patient in a longitudinal CCD. |
| Estimated number of stakeholders capturing, accessing using or exchanging | This would also be a level 2 element that would pertain to anyone who is having or has had a procedure. |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | N/A |
| Additional Specifications | N/A |
| Current Use | Not currently captured or accessed with an organization |
| Number of organizations/individuals with which this data element has been electronically exchanged | N/A |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | None |
| Restrictions on Use (e.g. licensing, user fees) | None |
| Privacy and Security Concerns | A procedure provenance is a sensitive element and must be treated as such. Like all patient information, the information captured under procedure provenance should not be shared in a way prohibited by applicable law. |
| Estimate of Overall Burden | This would be an additional element for vendors to add to a CCD under the procedure section so there would need to be a potential build out and a possible upgrade. Providers would then need to start recording this in the procedure section in a patient’s record. |
| 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 | Comment Level - Used by few stakeholders, or for narrowly defined conditions or events |
| Evaluation Comment | Thank you for your submission. Not currently captured or accessed by an organization. |
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