|Submitted By: Steven Lane / Sutter Health|
|Data Element Information|
|Rationale for Separate Consideration||While most EHRs include a date field associated with each diagnosis, this field may be used variably to denote the date of entry, onset, diagnosis, etc. Having a specific field to specify the date that a given diagnosis was made would support the determination of disease prevalence and support research and public health activities.|
|Use Case Description(s)|
|Use Case Description||Having a specific field to specify the date that a given diagnosis was made would support the determination of disease prevalence and support research into disease progression as well as public health activities. Knowing the amount of time that a patient has had a given disease can also support clinicians and those managing the health of populations to predict the timing/rate of the development of complications and/or disease progression.|
|Estimated number of stakeholders capturing, accessing using or exchanging||All clinicians could utilize this data to determine the duration of a disease process|
|Maturity of Use and Technical Specifications for Data Element|
|Current Use||In limited use in production environments|
Cancer and some other disease registries capture date and often the manner of diagnosis for relevant conditions.
|Number of organizations/individuals with which this data element has been electronically exchanged||4|
Cancer registries receive this data from cancer registrars as part of routine reporting.
|Restrictions on Standardization (e.g. proprietary code)||N/A|
|Restrictions on Use (e.g. licensing, user fees)||N/A|
|Privacy and Security Concerns||N/A|
|Estimate of Overall Burden||EHRs and other HIT systems likely all capture, at least in audit trail/metadata, the date that a diagnosis was entered into the active problem list and/or medical history list. This is quite different in meaning than the Date of Diagnosis so additional date fields would need to be added, the data stored in the database, data added to interoperability payloads for send, receive, ingestion, etc..|
|Other Implementation Challenges||There would be a need to develop and maintain a clear definition of how this field is to be populated as well as a determination of what types of actors should be allowed to populate or update this data field. Would also need to define how to capture and maintain a provenance history for this data elements that could eventually travel with the data as it is transmitted between HIT systems.|
Information about a condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.
Date of Diagnosis
A date field associated with each diagnosis on a patients problem list and/or medical diagnosis history to capture the date a patient first had the diagnosis. One could imagine, in the future, supplementing this with additional data elements for capturing identifying information for the individual making this determination, their role (physician vs. other healthcare professional, etc.), institution, some categorization of the basis for the determination (symptoms, signs, laboratory abnormality, etc.)