Author Role(s)

The metadata, or extra information about data, regarding who created the data and when it was created.

Data Element

Author Role

Description (*Please confirm or update this field for the new USCDI version*)

Category of actor that participated in the creation or revision of data.

Usage note: The source of the information can be used to form assessments about its quality, reliability, trustworthiness, or can indicate where to go to determine the origins of the information.

Examples include but are not limited to provider, patient, family member, and device.

Submitted By: Gary Dickinson / EHR Standards Consulting
Data Element Information
Rationale for Separate Consideration	Author role(s) are crucial to identify participation in action taken and/or authorship of specific data classes or data elements. It offers essential assurance for transparency, accountability, trust, traceability and data integrity.
Use Case Description(s)
Use Case Description	All use cases (including health data/record exchange) where essential assurance of transparency, accountability, trust, traceability and data integrity is required.
Estimate the breadth of applicability of the use case(s) for this data element	Any/all stakeholders for any/all use cases.
Healthcare Aims	Improving patient experience of care (quality and/or satisfaction) Improving the health of populations Reducing the cost of care Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)	N/A
Additional Specifications	N/A
Current Use	Extensively used in production environments
Supporting Artifacts	FHIR Core Release 4.0.1 – Record Lifecycle Event Implementation Guide ISO 21089:2018 – Trusted End-to-End Information Flows ISO/HL7 10781 – Electronic Health Record System Functional Model, Release 2.1 http://hl7.org/fhir/ehrsrle/ehrsrle.html
Extent of exchange	5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)	None
Restrictions on Use (e.g. licensing, user fees)	None
Privacy and Security Concerns	None. In fact enables health data/record audit events and audit logs (audit trails). • Who did what when where and why (actions taken) • Who documented what when where and why (health record entries)
Estimate of Overall Burden	As stated previously, most all of the submitted Provenance elements are intrinsic to what the source EHR/HIT system already knows, thus will not require extra data collection (burden) by the clinician or other end user.
Other Implementation Challenges	The usual resistance from certain stakeholders – those who believe Provenance is unnecessary – after all, who would believe that transparency, accountability, assurance, traceability and data integrity are essential/integral to trusted health data/record management and use?

ASTP Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards	Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use	Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3 Maturity - Current Exchange	Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4 Use Case(s) - Breadth of Applicability	Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by hswmin on 2024-03-22

THIA Support for Author, Author Role

The Texas Health Informatics Alliance (THIA) Policy and Standards Working Group support including legal author and author role to provide important information for better clinical decision-making. We recommend a national definition for legal author as various states may have different definitions. This is especially critical for institutions that provide clinical services between/across states or provide care to patients from other states.

THIA Policy & Standards WG - USCDI v5 Recommendations - Provenance - Author, Author Role.pdf

Submitted by yale-coredQMRoadmap on 2023-09-19

CMS-CCSQ Support for Author Role(s): adv. from Lev. 0 to Lev. 1

CMS-CCSQ supports the PACIO Project’s recommendation of the advancement of the Author Role(s) data element from Level 0 to Level 1. This data element represents necessary metadata around documents to validate and accurately understand the information that is gathered from numerous sources

Submitted by gldickinson on 2023-08-07

HL7 FHIR Record Lifecycle Event Implementation Guide

Please add/update reference to HL7 FHIR Record Lifecycle Event Implementation Guide, published December 2023: http://hl7.org/fhir/uv/ehrs-rle/Informative1/

Submitted by dididavis on 2021-09-30

Sequoia Data Usability Workgroup Support for Author Role Element

The Sequoia Project Interoperability Matters/Data Usability Workgroup conducted a clinician workshop on June 1, 2021 where feedback was given that it would be desirable to add a role element to provenance to identify what type of provider documented the information exchanged (i.e. Pharmacist, Nurse Practictioner, PCP, etc.). On behalf of the Data Usability Workgroup, I would like to support this submission for consideration, however the role types may not be consistent based on review of the value sets. Either way, I am trying to avoid duplication. Please contact let us know if we can provide additional input.