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Advance Functioning Data Class to Level 2

On behalf of the American Physical Therapy Association, please find below our comments outlining the rationale and evidence to support why the data class of "Functioning" should be moved from “Comment” to “Level 2,” based on overall value of the data elements, the maturity of terminology standards used, and broad implementation by the community. In 2001, the World Health Assembly approved the International Classification of Functioning, Disability and Health (ICF) as a framework for describing and organizing information on functioning and disability. As discussed in the ICF, functioning is a dynamic interaction between a person’s health condition, environmental factors, and personal factors. Functioning refers to all body functions, activities, and participation, while disability refers to impairments, activity limitations, and participation restrictions. Functioning is what a person with a health condition can do in a standard environment (their level of capacity) such as in a clinic, as well as what they do in their usual environment (their level of performance) such as the home, office, etc. Functioning includes actions and tasks executed by individuals (activities) and involvement in life situations (participation). Functioning within a person’s environment is important for daily life activities, such as bathing, toileting, and making meals; it also is important for socialization and participation in society such as working, going to school, or attending religious activities. If there are barriers to a person’s function, such as the inability to walk, lift, and carry due to a health condition (e.g., an injury or illness) or a barrier (such as stairs for a person with weakness in the legs), the person may be unable to perform routine tasks such as shopping to get food, picking his/her child up from the crib, driving a car, etc. Disruption to a person’s functioning or the inability to function can cause multiple complications ranging from additional medical conditions, to physical and social isolation, to strained personal relationships. For example, the inability to walk or the increased effort required to move from one place to another can lead to sedentary lifestyle behaviors such as lack of exercise, decreased movement, or contractures in joints, which in turn can lead to obesity, elevated blood pressure, and other more serious health conditions. Prevention of these secondary complications is key to ensuring patients' health and wellbeing. Functioning is pervasive across all aspects of care, and as such, other health care providers depend upon physical therapists to relay information about patient functioning; it is relied upon when making determinations about whether a patient can be discharged to their home/community or whether additional care is more appropriate, for example. APTA conducted an informal survey in February 2021 seeking information from physical therapists regarding documentation of functioning and how information on functioning is shared with other providers. We received feedback from more than 200 organizations across the continuum of care:
  • Large health systems (4)
  • University outpatient system (4 locations)
  • Rehab agency (1)
  • Home health agency (1)
  • Rehabilitation contract therapy company (1) that works with skilled nursing facilities and home health agencies
  • Physical therapist private practices (urban and rural), including:
    • 200+ companies representing 650 locations and 2,650 providers
    • 1 company with 500+ locations
As outlined in detail below, the most common subdomains of functioning captured within EHR systems across settings is mobility and self-care. This information about functioning is consistently being shared among providers and across health care settings as well as with patients. Every provider indicated that their EHR system allows them to capture information on function. EHRs utilized by these providers include:
  • A2C
  • Athena Health
  • Cadurx
  • Caretracker
  • Casamba
  • Cerner
  • Clinicient
  • Clinic Controller
  • Epic
  • Fusion WebClinic
  • Gentiva
  • HomeCare HomeBase
  • NextGen
  • Office Ally
  • RainTree
  • WebPT
As listed below, functioning is documented in a variety of ways across these EHRs:
  1. General text
  2. Discrete data (rolling, sitting, transfer from supine to sit)
  3. Sub-categories (mobility, self-care) and general text
  4. General text and sub-categories
  5. General text; sub-categories (mobility, self-care, etc.); free text; and discrete data
All providers surveyed reported that they share information on functioning with providers outside of their organization, although the method of communicating information on patient functioning to other providers varies. While small practices reported difficulties in sharing information in a standardized format, large practices and large health systems are sharing it consistently using data standards like direct messaging, C-CDA Level 1, and C-CDA Level 3 documentation. Mechanisms for sharing such information include:
  • Send records using data standards (C-CDA Level 1, Level 3)
  • AllScripts
  • Direct messaging
  • Secure portals
  • Print and fax records
  • Print the entire note and send to another provider in a HIPAA-compliant fashion
  • Secure email with PDF
As demonstrated above, information on functioning is broadly collected, used, and exchanged in different settings and within different EHR systems. It is collected upon evaluation and is relied upon to inform the plan of care; functioning is documented within each treatment note, progress report, and upon discharge. Clearly, patient functioning pertains to most or all patients and is relevant to all providers who care for such patients, including oncology, cardiology, primary care, and public health. Moreover, the inclusion of the functioning data class within the USCDI would help EHR communities better understand the direction that ONC is moving towards and the importance of sharing aspects of functioning. APTA also supports data elements within the Functioning data class that rely on the conceptual framework of ICF. Therefore, APTA recommends that ONC advance the functioning data class from the “Comment” level to at least “Level 2” to ensure consideration for inclusion in a future version of the USCDI.

Advance Functioning Data Class to Level 2

Functional status is a serious omission from USCDI.  It is a significant predictor of readmissions (Shih, S.L., Gerrard, P., Goldstein, R. et al. Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients. J GEN INTERN MED 30, 1688–1695 (2015)., length of stay (Huggan PJ, Akram F, Er BH, Christen LS, Weixian L, Lim V, Huang Y, Merchant RA. Measures of acute physiology, comorbidity and functional status to differentiate illness severity and length of stay among acute general medical admissions: a prospective cohort study. Intern Med J. 2015 Jul;45(7):732-40. doi: 10.1111/imj.12795. PMID: 25944281), and death (Formiga F, Ferrer A, Padros G, Montero A, Gimenez-Argente C, Corbella X. Evidence of functional declining and global comorbidity measured at baseline proved to be the strongest predictors for long-term death in elderly community residents aged 85 years: a 5-year follow-up evaluation, the OCTABAIX study. Clin Interv Aging. 2016 Apr 18;11:437-44. doi: 10.2147/CIA.S101447. PMID: 27143867; PMCID: PMC4841391). As noted in several other comments, there are elements of functional assessment and associated vocabularies currently in wide use.  As an example, the CMS Data Element Library (DEL) contains the data elements used in the federally mandated assessment instruments across all post-acute care settings. All DEL elements have associated LOINC codes; and they are currently being mapped to C-CDA templates. The PACIO Project is focusing on both functional status and cognition elements within the DEL to establish FHIR resources. Function is so important that it needs a placeholder in USCDIv2 even if it is incomplete. It would be reasonable to add a “Functioning” data class to USCDIv2 and initially populate it only with the functional status data elements from the DEL that have LOINC codes and that are mapped to C-CDA templates.  Although incomplete, it would be a start. Additional assessment instruments, data elements and subcategories of function can be added in subsequent versions.   

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