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

Data Element
Portable Medical Orders
Description

Orders for certain aspects of medical care, including end-of-life care, which support a transfer of care request from one practitioner or organization to another that provides end-of-life or life-sustaining care services. Different types of portable medical orders are used in different jurisdictions.
Submitted By: Grace Glennon on behalf of Joel Andress and CMS-CCSQ / On behalf of Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Rationale for Separate Consideration A data element encompassing orders for all services (Types of orders for medical care/services ) is a Level 2 element, but we believe a data element specifically for end of life care orders should be included, due to the high priority nature of these specific orders, and the USCDI taskforce recommendation to prioritize the concept. Additionally, the COVID-19 pandemic has renewed the push for an expansion of end of life care services with thousands of Americans suffering from long-term, debilitating symptoms. End of life care, like palliative care, has also been associated with a higher quality of life and better pain management in patients who have received these services.

https://www.healthit.gov/sites/default/files/facas/2021-04-15_USCDI_Task_Force_Recommendations_508.pdf
https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/04/20/long-haul-covid-renews-push-to-expand-palliative-care
https://www.who.int/news-room/fact-sheets/detail/palliative-care
Use Case Description(s)
Use Case Description Portable Medical Orders, including orders (service requests) for end of life care services are used extensively by hospitals, clinicians and providers, and are included in CMS quality measurement. They are important for quality improvement, clinical decision support, and measurement to ensure proper patient populations are provided the proper end of life care as needed. These data are necessary to confirm appropriate and high quality of care is received for patients across different populations. It is clinically relevant from a care perspective and a quality measurement perspective.

Currently, CMS quality eCQMs include the order concepts for end of life care services, including hospice, comfort care, palliative care.
Estimate the breadth of applicability of the use case(s) for this data element More than 4,000 hospitals and 1 million providers currently capture, access and exchange this order (service request) information. This information is currently electronically submitted by providers and hospitals to CMS for quality measurement.
Link to use case project page https://ecqi.healthit.gov/ecqms :eCQI resource center, includes measure specifications for CMS program eCQMs (i.e. CMS 69, CMS 347, CMS 506, CMS 159)
Use Case Description Each step in the chain of events between a clinicians request for an end of life care service (order) and the completion of that service is critical for vigilance and surveillance of patient safety and appropriate care. It is important to have the capacity to evaluate the clinicians intent and the actual completion across care settings and across time. Specifically, this concept supports care coordination by allowing for transfer of information of the order to be completed if the service is not being provided by the same organization.
Estimate the breadth of applicability of the use case(s) for this data element All healthcare providers and hospitals using EHR systems should have order information for end of life care services documented and accessible.
Link to use case project page https://ecqi.healthit.gov/ecqms
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) SNOMED CT
ICD-10
CPT

Examples:
Comfort Measures SNOMED CT Value set: 1.3.6.1.4.1.33895.1.3.0.45
Hospice Care Ambulatory Value set: 2.16.840.1.113883.3.526.3.1584
ICD-10 Encounter for palliative care: Z51.5
HL7 Service Type value set: https://www.hl7.org/fhir/valueset-service-type.html
https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
Additional Specifications HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request Profile: http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-servicerequest.html

US CORE Implementation Guide: Service Request noted as a future profile under consideration: https://www.hl7.org/fhir/us/core/future-of-us-core.html

HL7 FHIR ValueSet Service Type: Includes hospice care, palliative medicine (https://www.hl7.org/fhir/valueset-service-type.html)

HL7 FHIR Quality Measure STU2 for FHIR R4 Implementation Guide, Library-Hospice (http://hl7.org/fhir/us/cqfmeasures/Library-Hospice.html)
Current Use Extensively used in production environments
Supporting Artifacts Orders (service requests) for end of life care services are routinely captured in EHR systems used by hospitals and providers for the use 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).
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs ; https://ecqi.healthit.gov/ecqms
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.
Supporting Artifacts End of life care orders (service requests) 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 architectures. These orders (service requests) data elements have been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly exchanged. Ongoing testing for exchanging these data in FHIR standards via HL7 Connectathons.
https://ecqi.healthit.gov/qrda; https://confluence.hl7.org/display/FHIR/2021-09+Clinical+Reasoning
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No challenges anticipated. These data are 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 These data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data element.
Estimate of Overall Burden Orders (Service requests) for end of life care are regularly captured by a broad range of healthcare providers, and should not cause burden to implement. Some burden required to include a ServiceRequest profile as a US Core profile, though it is already noted as a potential addition for future iterations, and built out in QI Core.
Other Implementation Challenges N/A
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 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by mturchioe on

ANI's comment on USCDI v6: Portable Medical Order

The Alliance for Nursing Informatics (ANI) strongly supports this addition. However, we recommend greater specificity in both the use cases and the data model implications. For example, consider a scenario where a patient has a DNR order recorded in their primary care provider’s or nursing home’s EHR, but it is unknown to EMS responders or clinicians at a hospital during a 911 call. To support real-world interoperability, we suggest clarifying how this data element should be modeled (binary or requiring metadata such as type of order, issuing clinician, date, jurisdiction), specific expectations for accessibility (queryable in real-time by EMS even if outside the health system), and guidance for ensuring exchangeability across settings.

Please see previously submitted ANI comments for additional recommendations.

Submitted by jpatterson@mitre.org on

PACIO Appreciates Inclusion of PMO, Recommends Changes

  • Data Class: Orders
  • Data Element: Portable Medical Order (Draft V6)
  • Recommendation: Advance and include Portable Medical Orders in the final USCDI V6, renaming the data element Portable Medical Order AND update the description of what this data element represents.
  • Rationale: The PACIO Project Community* would like to thank ASTP for recognizing the importance of the Portable Medical Order data element and its inclusion in the Draft USCDI V6. The community continues to strongly recommend its inclusion in the final USCDI V6.
  • The PACIO Project Community also recommends updating the description of the Portable Medical Order data element to provide the broader understanding of its application. The NEW Proposed Description follows:
    • Information about a provider authored portable medical order document indicating its location, content, type, version of document (current versus superseded for example) and verification status.
    • Usage note: The Portable Medical Order may include structured or unstructured data which indicates whether a person has one or more portable medical order documents, the type of portable medical order, the location of the document, and whether it has been verified. Such documents may be used in the event a person is unable to communicate to a treating provider, such as during an emergency or health crisis, to convey their preferences for CPR and/or life-sustaining treatment interventions. These documents often also include goals of care.
    • Examples include but are not limited to an indication that a POLST (Portable Medical Order for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), out-of-hospital DNR (do-not-resuscitate) or similar document is on file, a reference to the location of the portable medical order document, and the validating provider.
  • This change to the description, modeled after the “Advance Directive Observation” data element, supports the need for patients and their providers to access and honor these important documents even as the healthcare industry moves from paper-based and unstructured document (PDF) workflows to more efficient, verifiable, and person-centered data exchange/access document workflows.
  • As FHIR US Core IG and CDA currently support exchange and access to unstructured data and documents, the projects that are quickly moving to balloted FHIR and CDA IGs for these kinds of documents can provide the needed guidance to support structured data exchange without risk of leaving these critical life-and-death, legally enforceable documents behind.
  • * 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.

Submitted by HCapon on

PACIO Supports Portable Medical Order in V6

  • Data Class: Orders V5 
  • Data Element: Portable Medical Orders (Level 2) 
  • Recommendation: Advance and include Portable Medical Orders in the final draft of USCDI V6 and rename the element “Portable Medical Order.” 
  • 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, data elements for an Order and Portable Medical Order are similar but have fundamental differences that must be captured separately to ensure expert clinical care in the appropriate settings. Portable Medical Orders are setting agnostic and follow a patient between settings. They are in essence orders that are written without a known final destination when they come into effect. They do not expire when a patient is discharged from a facility, and they do not need to be rewritten by a receiving clinician to remain actionable. This differs from the concept of an Order, and we believe both should be captured as separate data elements to aid in their retrieval and use. 
  • In the same way we believe Orders and Order are notionally different, we believe Portable Medical Orders could be mistakenly interpreted as a list or summary of portable medical orders. We believe the data element should be renamed “Portable Medical Order” to clarify that this element is meant to exchange the complete order and its contents, not a list or summary. This change is meant to facilitate the exchange of existing unstructured documents that are used hundreds of thousands of times per month and structured data as it becomes more available. 

Submitted by rdillaire on

CMS-CCSQ Support Portable Medical Orders for USCDI v6

Data Element: Portable Medical Orders (Level 2)

  1. Recommendation: Add the Portable Medical Orders data element to Final USCDI v6 and rename to ‘Portable Medical Order.’
  2. Rationale: Portable Medical Orders are an important component of patient preferences. They do not have a specific deadline or destination when written. They do not expire and follow the patient between care settings. Value sets under development with the draft Advance Directive Interoperability (ADI) IG also support portable medical orders. Additionally, the term “orders” is not aligned with how others in the data class are named, as they are all singular. There is a notional difference in singular versus plural terminology. Therefore, we request including this data element in USCDI v6 and aligning this data element with related terminology by renaming it “Portable Medical Order.”

Submitted by yale-coredQMRoadmap on

CMS-CCSQ/CDC Joint for Orders for End of Life Care for USCDI v5

CMS-CCSQ recommends this Level 2 data element be added to USCDI v5. Orders for End of Life Care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life and is yet to be represented in USCDI. These data are routinely captured in EHR systems and need to be interoperable and exchangeable to reduce discordance between care provided and patient wishes, and to enhance value of care at end of life. This critical information is required to support a transfer of care request from one practitioner or organization to another that provides end-of-life care services. This data element was previously identified as a joint CMS-CDC priority and supports advancing patient care quality.

Submitted by yale-coredQMRoadmap on

Cntd. CMS-CCSQ Support for Orders for End of Life Care for v4

Orders for end of life care (comfort care, palliative care, hospice) include information that has the power to actionably communicate an individual’s wishes at their end of life and is yet to be represented in USCDI. These data need to be interoperable and exchangeable to reduce discordance between care provided and patient wishes, and to enhance value of care at end of life. This data element continues to be a joint CMS-CDC priority and supports advancing patient care quality, which aligns with the purpose of the USCDI (setting a foundation for broader sharing of electronic health information to support patient care).

Maturity: ONC recently advanced this data element to Level 2 based on maturity of standards.

  • Current standards:
    • Newly added—HL7 FHIR US CORE Implementation Guide STU 5, Service Request Profile (http://hl7.org/fhir/us/core/StructureDefinition-us-core-servicerequest.html)
    • HL7 FHIR QI Core Implementation Guide STU4 based on FHIR R4, Service Request Profile (HL7.FHIR.US.QICORE\QICoreServiceRequest - FHIR v4.0.1)
    • Concepts captured in mature terminology: LOINC, Systematized Nomenclature of Medicine (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. The relevant information required to support a transfer of care request from one practitioner or organization to another that provides end of life care services is critical.

Submitted by HCapon on

PACIO Project Comments on Orders for End of Life Care

  • Data Class: Orders (Level 2) 

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

  • Recommendation: Change the name of the data element “Orders for End of Life Care” to “Portable Medical Orders”.   

  • Rationale: Conceptually, including data elements for Orders for End of Life Care and Portable Medical Orders for Life-Sustaining Treatment is in the USCDI duplicative. 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. There is currently a data element entitled, “Portable Medical Orders for Life-Sustaining Treatment” under the Orders data class in the USCDI Comment Level. Therefore, we recommend inclusion of one of these data elements in the USCDI V4, but suggest the name of the data element included should be Portable Medical Orders for Life-Sustaining Treatment, in order to encompass a broader range of clinical encounters. 

Submitted by HCapon on

PACIO Project Support to Advance 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 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. 

Submitted by PACIO-Project on

PACIO Support to Advance Orders for End of Life Care

Advance the “Orders for End of Life Care” data element under the Order data class to USCDI v4.  It is recognized that the previous concept of “Portable Medical Orders for Life-Sustaining Treatments” was too narrowly focused and additional practitioner-authored orders related to goals of care and specific medical treatments or interventions should be included. These orders for end of life care are established by a practitioner regarding treatments that restore, sustain, or prolong a patient’s life. These types of medical orders are intended to be consistent with the patient’s instructions and wishes.

The PACIO Community strongly recommends this data element be promoted to USCDI V4.

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