Provider-authored directive for the delivery of patient care services.

Data Element

Applicable Vocabulary Standard(s)

Orders

Provider-authored directive for the delivery of patient care services.

Examples include but are not limited to diagnostic imaging, laboratory tests, interventions, referrals and consultations, and do-not-resuscitate.

Comment

Orders should be addressed in their respective data classes

Orders vary in their information models and terminology bindings from data class to data class, so my recommendation is to roll up orders into their corresponding data classes rather than to treat "Orders" as its own data class. For example, a medication order (prescription) would belong under the Medicaion data class, have RxNorm as its applicable vocabulary standard for the medication, and could have further specification for route, frequency, refills, and other medication-specific order characteristics. On the other hand, a lab order would belong under the Laboatory data class, would likely have LOINC as its applicable vocabulary standard for the lab test to be performed and could have further specification for specimen source, repetitions, and other lab-specific characteristics. A diagnostic imaging order would belong under the Diagnostic Imaging data class, would likely have LOINC as its applicable vocabulary standard for the imaging test and could have further specification for priority, laterality, and other diagnostic imaging characteristics. All of these domain-specific characteristics could be fleshed out over time (while being mindful about the varying degrees of pre-coordination and post-coordination that might make sense for orders), but the point is that I think we are dealing with a heterogenous collection of orders and order details that need to be addressed separately.

The original request for "Provider-authored directive for the delivery of patient care services" included examples such as "diagnostic imaging, laboratory tests, interventions, referrals and consultations, and do-not-resuscitate" which are essentially all examples of different kinds of procedure orders. While a Procedures data class does exist, as we aim to support orders for these diverse procedures, it may be that new data classes and/or data elements need to be added in a similar manner to how the Diagnostic Imaging data class (essentially a "Diagnostic Imaging Procedure") was added to differentiate from the somewhat nonspecific Prodedures data class. For example, to support the "referrals and consultations" example, there could be a new "Referrals" data element in the Procedures data class that would have associated characteristics such as department, provider, Reason for Referral (which already exists), and other characteristics. For now, DNR/POLST/MOLST might fit best under the Procedures data class. It might warrant a new data element, perhaps "Resuscitation Orders" or something similar. The characteristics could be fleshed out and proposed for future public comment where there might be ways to describe patient preferences for chest compressions, mechanical ventilation, blood transfusion, etc.

PACIO Recommendation for PMOLST Data Element

  • Data Class: Orders (Level 0)
  • Data Element: Portable Medical Orders for Life-Sustaining Treatments (Level 0)
  • Recommendation: Remove the Portable Medical Orders for Life-Sustaining Treatments data element under the Orders Data Class in Level 0 and do not consider this data element for inclusion for future versions of USCDI.
  • Rationale: The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. Conceptually, including data elements for “Orders for End of Life Care” (Level 2) and “Portable Medical Orders for Life-Sustaining Treatment” (Level 0) in the USCDI is duplicative. Our preferred language would be “Portable Medical Orders” rather than “Orders for End of Life Care,” because we have found jurisdictions that utilize “Portable Medical Orders” during encounters that are NOT related to EOL care. “Portable Medical Orders” would be more broadly applicable than either “Orders for End of Life Care” or “Portable Medical Orders” for Life-Sustaining Treatments, but in any case, only one data element should be included in future versions of USCDI to represent this concept.

PACIO Recommendations on Orders and Orders for End of Life Care

  • Data Class: Orders (Level 2)
  • Data Element: Orders for End of Life Care (Level 2)
  • Recommendation: Include the “Orders” data class in USCDI V5 and change the name of the data element “Orders for End of Life Care” to “Portable Medical Orders” and include it in the USCDI V5 under the Orders data class.
  • Rationale: The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. The PACIO Community believes the data elements “Care Experience Preferences,” “Treatment Intervention Preferences,” “End of Life Orders” and “Durable Medical Power of Attorney” included together provide the most essential information to give a holistic view of the individual’s wishes, necessary to inform care. The PACIO Community appreciates that the “Care Experience Preferences” and “Treatment Intervention Preferences” data elements have been included as data elements in USCDI V4, but to maximize the clinical utility of this information we recommend also advancing “Orders for End of Life Care” as a data element in V5. Although our priority would be to include information capturing the concept of “Orders for End of Life Care” in USCDI V5, we recommend renaming this data element “Portable Medical Orders.” Conceptually, data elements for “Orders for End of Life Care” and represent the same clinical concept, but “Portable Medical Orders” is a more inclusive and appropriate term. We have found jurisdictions that utilize “Portable Medical Orders” during encounters that are NOT related to EOL care. In Maryland, for example, a Medical Order for Life-Sustaining Treatment (MOLST) should be prepared for all clinical encounters with an adult, regardless of health status. We propose the data element, “Orders for End of Life Care” be renamed "Portable Medical Orders" to expand the application of this concept for all US jurisdictions and in order to encompass a broader range of clinical encounters.

PACIO Project Support to Include Orders Data Class

  • Data Class: Orders (Level 2) 

  • Data Element: Orders for End of Life Care (Level 2) 

  • Recommendation: Include the “Orders” data class and “Orders for End of Life Care” as a data element under that class in USCDI V4. 

  • Rationale: The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. The PACIO Community believes the data elements Care Experience Preferences, Treatment Preferences, End of Life Orders and Durable Medical Power of Attorney included together provide the most essential information to give a holistic view of the individual’s wishes, necessary to inform care. The PACIO Community appreciates that the Care Experience Preference, Advance Directive Observation, and Treatment Intervention Preferences data elements are planned for the Goal data class in V4, but to maximize the clinical utility this information we recommend also advancing Orders for End of Life Care as data element in V4. As stated previously, we understand expanding these concepts beyond advance healthcare decision documents to a more broad utilization than our use case which we have no objection to. 

Support for orders and request for data model clarity

We support the USCDI TF and HITAC recommendations to prioritize medical orders for life sustaining treatment (POLST/MOLST) and End of Life Care Orders as noted by CMS-CCSQ. We also concur with Lisa Nelson's sentiment that additional thought should be given to the data model structure for representing orders more generally.

CMS-CCSQ Support for Orders in USCDI v3

CMS-CCSQ  continues to support inclusion of the broader Orders data class to capture and exchange all orders for medical services (service requests). This information confirms appropriate and high-quality care is provided in quality measurement, is relevant information required to support a referral or a transfer of care request from one practitioner or organization to another, and is used for prior authorization activities.

 

CMS-CCSQ also recommends inclusion of an End of Life Care Orders data element defined as orders for hospice, palliative care, and comfort care.

Rationale:  End of life care orders are especially critical for care coordination and care decision making. This concept may be used to share relevant information required to support a transfer of care request from one practitioner or organization to another that provides end of life care services, which often happen at different organizations. Interoperability of these orders would also allow orders to move more easily between organizations, facilitating patient choice.

Maturity:

  • Current standards:
    • Orders can be exchanged in mature FHIR standards, including Service Request profile included in QI Core.
    • End of Life Care concepts are captured in mature terminology: LOINC, SNOMED
  • Current uses, exchange, and use cases: Orders (service requests) for end-of-life care services are routinely captured in EHR systems used by hospitals and providers and are used in CMS quality reporting eCQMs across programs including IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of order (service request) related data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes orders (service requests) for an intervention (i.e., palliative care, hospice, comfort care).

Do you intend the USCDI to support a multiaxial heirarchy?

If you make Orders a Data Class, then you need to decide if you will allow notions to be categorized in more than one place or not.  For example, orders for laboratory, pathology, and diagnostic imaging tests, should those data elements be covered in those respective data classes, or should those data elements be shown within the Orders data class?  Or should they show in both places?

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