Submitted by HCapon on
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.
Submitted by victor_lee on
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.