Submitted by JAndress316 on 2021-04-15
|Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)|
|Data Element Information|
|Rationale for Separate Consideration||Problems, defined by SNOMED codes, are included in the USCDI version 1. However, there are use cases that require explicity information about the primary reason for an encounter and associated diagnoses/problems.|
|Use Case Description(s)|
|Use Case Description||Encounter information is used extensively by hospitals, clinicians and providers submitting data for quality measurement. This patient level encounter information provides context for when, why and what type of healthcare encounters occurred which may have led to conditions diagnosed, procedures performed, or medications prescribed. It is used in quality measurement to define a population for measurement based on time of encounter occurrence, and encounter reason, or the location within a hospital an encounter occurred.
It is also critical context for clinicians interpreting transferred information. For example, contextualizing an eGFR measure during an acute care hospitalization excludes it from use in categorizing a patient’s stage of chronic kidney disease. For quality assessment, the context of encounters is the cornerstone of attribution and accountability for performance.
|Estimated number of stakeholders capturing, accessing using or exchanging||More than 4,000 hospitals and 1 million providers are currently capturing, accessing and exchanging this encounter level information. This information is currently electronically submitted by providers and hospitals, or their Health IT firms/EHR vendors, to CMS for quality measurement.|
|Link to use case project page||https://ecqi.healthit.gov/ecqms|
|Use Case Description||Data exchange of encounter information is also critical for clinical care. Clinicians need to be aware of recent healthcare encounters, including the type of encounter, the reason for the visit, how recent that encounter was (date/time) and discharge disposition and diagnosis in order to provide relevant and quality care for the patient thereafter.
Currently, this type of encounter information is exchanged as part of care coordination and admission/discharge/transfer notifications as part of ONC interoperability standards.
|Estimated number of stakeholders capturing, accessing using or exchanging||All healthcare providers using certified electronic health record technology (CEHRT) should be capturing, accessing, using and exchanging these encounter data elements.|
|Link to use case project page||https://www.healthit.gov/isa/section-ii-contentstructure-standards-and-implementation-specifications|
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||Encounter type/occurrence:
SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307)
HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087)
CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001)
HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html
Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis:
Code System http://terminology.hl7.org/CodeSystem/discharge-disposition
|Additional Specifications||HL7 FHIR US Core Implementation Guide STU3 based on FHIR R4, Encounter profile. (https://www.hl7.org/fhir/us/core/index.html) Encounter status, class, type, period (timing), reason, location, discharge disposition all must have/must support data elements
This Encounter profile is also required by the US Core IG Capability Statement. (https://www.hl7.org/fhir/us/core/capstatements.html)
CMS Quality Data Model (QDM) version 5.5 Guidance (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf)
HL7 C-CDA Release 2.0 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492)
|Current Use||This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders|
Encounter data is routinely captured in EHR systems used by hospitals, providers, and other healthcare stakeholders. Encounter-based EHR data is submitted by providers to CMS via QRDA I and III files and other data architectures from hospitals, providers, health IT firms, and vendors for eCQM public reporting in CMS IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of patient and encounter based data for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT)—this includes encounter details including admission and discharge date/times or office visit date/times to determine which patients are included in the measurement periods, type of encounter, and encounter diagnoses/primary reason, discharge dispositions, and encounter location details to determine the population of interest, or measure exclusions.
Widely available in EHR systems:
|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.|
Encounter data for quality measurement is electronically exchanged from organization’s EHR systems to CMS for reporting and payment quality measurement programs, via QRDA files and other data architectures. These encounter data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly electronically captured and exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
Encounter data has also been electronically exchanges with external organizations via C-CDA, as part of ONC’s requirements and a part of data exchange for the continuum of care to notify of admissions, discharges, and transfers of care.
|Restrictions on Standardization (e.g. proprietary code)||No challenges anticipated. This data is available in standard terminology that can be publicly access via the 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||Encounter data is regularly captured by a broad range of healthcare providers, and should not cause burden to implement. This data is already regularly exchanged and available in standardized fields and terminology. It is also required by the US Core Capability Statement and therefore will be stood up by those stakeholders complying with the ONC requirement for the Standardized FHIR API for patient and population services.|
|Other Implementation Challenges||N/A|
Submitted by LisaRNelson on 2022-04-29
Encounter DiagnosesThe USCDI V3 notion of “encounter diagnosis” needs further refinement to differentiate different types of encounter diagnoses. Outpatient encounter diagnoses need to be differentiated from inpatient encounter diagnoses because inpatient encounter diagnoses include both admission diagnoses and discharge diagnoses. In other care settings, such as Physical Therapy, they utilize three different types of encounter diagnoses: the billing diagnoses, medical diagnoses, and treating diagnoses. The proposed data element is not granular enough to support valuable interoperability. Greater standardization of the vocabulary used to express diagnoses also needs to be addressed. Current standards do not provide implementers with adequate and consistent guidance on mappings between ICD-10 and SNOMED CT. Duplicating the expression of problems in both SNOMED CT and ICD-10 adds burden and introduces complexities for information exchange. ICD-10, maintained by the World Health Organization, is the primary vocabulary for encoding diagnoses around the globe, and the vocabulary becomes increasingly expressive as it matures. SNOMED CT is well positioned to represent clinical findings and other non-diagnoses-related concepts. Focusing on the use of ICD for all diagnoses, without mandating it be translated to SNOMED CT would reduce a great deal of burden, better support interoperability, and allow greater consistency across V2, CDA, FHIR and other administrative information such as explanation of benefits.
USCDI V3 Comment 20220429_0.pdf