| Submitted By: Smitha Vellanky, on behalf of Joel Andress and Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) / On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
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| Data Element Information | |
| Rationale for Separate Consideration | Clinical notes provide important clinical information necessary for care coordination and patient care. Specifically, Emergency Department Notes should be a distinct clinical note data element to distinguish data from other Progress Notes, for the purposes of coordination of care and care continuity. This ensures capture of a critically unique encounter type that represents a key interface between and across acute and outpatient care settings. A separate Emergency Department Notes data element will also ensure patient access to this information. As historically vulnerable and underserved populations disproportionately use Emergency Departments for primary care, these clinical notes may be particularly useful in supporting the Office of the National Coordinator for Health Information Technology (ONC) United States Core Data for Interoperability (USCDI) v4 goals of addressing needs of underserved communities and public health interoperability needs related to emergency response. |
| Use Case Description(s) | |
| Use Case Description | Emergency department notes are complementary to the other clinical note data elements included in USCDI and will provide a complete picture of patient emergency department encounters. They are necessary for coordination of patient care across the care continuum. Emergency department notes are exchanged and used routinely throughout the course of care. Emergency Departments can be fully integrated within a healthcare system, fully independent and administratively distinct from a nearby healthcare or hospital system, or some intermediate state between these extremes. They represent a unique and critical connection between inpatient and outpatient care settings and are therefore an important component of both acute and chronic disease management. |
| Estimated number of stakeholders capturing, accessing using or exchanging | Emergency department notes are used widely in care coordination across healthcare systems and would be used by a large proportion of USCDI stakeholders. |
| Use Case Description | Clinical notes are a key component to communicate the status of a patient. Particularly in the context of transition of care, emergency department notes can provide additional information regarding patients’ health status at the presentation for care to inform care pathways as well as those care pathways. These notes are also important to ensure patient access to data and interoperability of data for care coordination and handoffs. |
| Estimated number of stakeholders capturing, accessing using or exchanging | This data element is captured commonly in electronic health records (EHRs) and used and exchanged broadly across health systems. |
| Healthcare Aims |
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| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | LOINC LOINC Group Code: Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain, LOINC LG41825-7 Or at a minimum, Emergency department Discharge summary note, LOINC 59258-4 https://loinc.org/ |
| Additional Specifications | HL7 FHIR US Core Implementation Guide STU5 based on FHIR R4: US Core Document Reference Profile; US Core Diagnostic Report Profile for Report and Note Exchange |
| Current Use | Extensively used in production environments |
| Supporting Artifacts |
EHRs routinely collect notes for patient encounters including Emergency Department visits. This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders. |
| 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. |
| Supporting Artifacts |
Emergency department notes are broadly collected and used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders. |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | No challenges anticipated. This data is available in standard terminology that can be publicly accessed via the Value Set Authority Center (VSAC) and HL7. |
| Restrictions on Use (e.g. licensing, user fees) | We are not aware of any restrictions. |
| Privacy and Security Concerns | This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data. |
| Estimate of Overall Burden | Emergency department notes are regularly captured as part of EHR systems. Most hospitals are already capturing and exchanging these notes pertaining to Emergency Departments. |
| Other Implementation Challenges | N/A |
| 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 | 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 |
| Evaluation Comment | This looks to be a level 2 |
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