Data Element
Submitted By: KarenP-SSA / Social Security Administration (SSA)
Data Element Information
Use Case Description(s)
Use Case Description SSA’s disability determination process requires the review of detailed medical records of disability applicants.
Due to the COVID-19 pandemic, SSA field offices are closed. This prevents disability applicants from submitting paper medical records they hold to those field offices. An alternative would be submitting this information to SSA electronically. A matter of convenience that would be used by few in normal times, the demand for this submission channel has mushroomed during the pandemic.
However, SSA cannot accept electronic medical records submitted by applicants because the integrity of those records cannot be verified without knowing the author and without (cryptographic) digital signatures of the content. Adding the Signature element to Provenance would provide content integrity verification and resolve this blocker for SSA disability applicants.
Estimate the breadth of applicability of the use case(s) for this data element 3 million disability applicant (patients) interact with SSA annually, involving 15-20 million medical records from almost 500,000 providers.
Link to use case project page https://github.com/SSAgov/HealthIT
Use Case Description As consumer-directed health information exchange becomes more prevalent, verifying the
integrity of patient-supplied medical information will become an imperative. When EHI obtained
by a patient that is digitally signed is provided to a third party along with the chain of trust from its
origin, that third party can have confidence in the integrity of that EHI. Consumer apps facilitating
the submission of sports physicals and immunization record to schools are inevitable—as are
apps driving patient-driven care coordination. Consumers will demand this access to their data,
and providers receiving that data will need to know it is unaltered.
Estimate the breadth of applicability of the use case(s) for this data element Health records are exchanged between millions of providers (and, increasingly, payers) through
dozens of health information exchanges (HIEs) in support of millions of patients every year.
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) HL7 FHIR R4 (v4.01: R4 – Mixed Normative and STU)
https://www.hl7.org/fhir/provenance-definitions.html
Additional Specifications FHIR Provenance Resource (v4.0.1) (https://www.hl7.org/fhir/provenance.html)
6.3.4.3 Signatures
The Provenance resource includes a signature element (digital signature) which can be used for standards based integrity verification and non-repudiation purposes. The Signature datatype provides details on use of the signature element. The Signature.type coded value of "Source" should be used when the signature is for simply proving that the resource content is the same as it was when the resource was updated or created.
Also: https://www.hl7.org/fhir/datatypes.html#Signature (2.24.0.17)
• Both XML and JSON cryptographic signatures are supported.

For Author:

In FHIR, (https://www.hl7.org/fhir/provenance.html): This would likely be “Provenance.agent.who”
Basic Provenance Informative Implementation Guide (for C-CDA Author Participation) (https://confluence.hl7.org/display/SEC/Basic+Provenance+Implementation+Guide?preview=/40740218/55940686/20190719_HL7_Basic_Provenance_Security_Posting.docx) does not mention signatures, but signatures are described as a CDA extension in HL7 Implementation Guide for CDA® Release 2: Digital Signatures and Delegation of Rights (http://www.hl7.org/documentcenter/public/standards/dstu/CDAR2_IG_DIGITALSIG_R1_DSTU_2014OCT.pdf) document. Author is a data element originally proposed by ONC for inclusion in UCSDI for Provenance.
• Specifications or IG updates may be required to align C-CDA to FHIR.
Current Use Not currently captured or accessed with an organization
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns Using these data elements will reduce privacy and security concerns about the EHI being exchanged.
Estimate of Overall Burden Author information should be readily available to implementers already populating Provenance data elements. Although Cryptographic signatures of content (“hashing”) is not widely practiced, the methodology for doing this is straightforward (and specified in detailed in the above-reference FHIR Provenance IG). Implementation should not require more than two two-week sprints.
Other Implementation Challenges None

Comment

Submitted by hswmin on

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_0.pdf

Submitted by Steven.Lane on

Clinician support for addition of Author to USCDI v5

Every USCDI task force / workgroup has recommended the addition of this data element to USCDI.

Essentially all HIT systems record and maintain the identity of the user who enters/authors clinical data into the system.  The author of specific information can impact the manner in which data is used by others.  Knowing the identity of the author is particularly important when the author is the individual/patient themselves, a family member, or a caregiver.  For many data classes, information authored by the patient will be considered to be the most reliable, e.g., when verifying current medications taken, allergies, etc., whereas for other data classes, such as detailed diagnosis specification, just the opposite may be true, depending on the individual interpreting the data. 

Submitted by yale-coredQMRoadmap on

CMS-CCSQ Support for Author for USCDI v5

CMS-CCSQ recommends this Level 2 data element be added to USCDI v5. It is important to know who the author of the medical notes and information is for effective care coordination and care transitions. With the move toward patient-centered care, there could be multiple contributors of data including patients and other caregivers. The Author data element will provide a complete picture of information from an outside entity. The current data elements in the Provenance data class, Author Time Stamp and Author Organization, will be more meaningful if they can be attributed to the source of the information i.e., the Author. Specifically, CMS recommends including all authors who contribute to the care and documentation of care of a patient, or at least the final legal author.

Submitted by yale-coredQMRoadmap on

CMS-CCSQ Support for Author for USCDI v4

CMS-CCSQ recommends the addition of the Author data element to USCDI. It is important to know who the author of the medical notes and information is for effective care coordination and care transitions. Provenance statements indicate clinical significance in terms of confidence in authenticity, reliability, and trustworthiness, integrity, and stage in lifecycle, all of which may impact security, privacy, and trust policies. The Author information is required for billing and therefore, is accurate and can support audit trails. With the move toward patient- centered care, there could be multiple contributors of data including patients and other caregivers. The Author data element will provide a complete picture of information from an outside entity. The current data elements in the Provenance data class, Author Time Stamp and Author Organization, will be more meaningful if they can be attributed to the source of the information i.e., the Author. Specifically, CMS recommends including all authors who contribute to the care and documentation of care of a patient, or at least the final legal author. For example, a medical student may initiate a note; it may then be reviewed and signed by the nurse, and ultimately signed off by the attending physician. This type of author trail is meaningful, and the attending physician is the clinician ultimately responsible for the care of the patient.

Maturity:

  • Current standards: o HL7 FHIR R4 (v4.01: R4 – Mixed Normative and STU) (https://www.hl7.org/fhir/provenance-definitions.html)
  • Current uses, exchange, and use cases: Author information is routinely captured in electronic health record (EHR) systems used by hospitals, providers, and other healthcare stakeholders, and should be readily available. Knowing the author of notes and records will allow for validation of the integrity of the data used in quality measures. This is meaningful information needed to ensure efficient care coordination along with the current Provenance data elements in USCDI.

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