Data Element
Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Data Element Description Represents the primary reason for a healthcare encounter and associated diagnoses, represented by a diagnosis code.
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.
Estimate the breadth of applicability of the use case(s) for this data element 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.
Estimate the breadth of applicability of the use case(s) for this data element 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
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Improving provider experience of care
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:
SNOMED CT
ICD-10-CM
Discharge Disposition:
DischargeDisposition
Code System http://terminology.hl7.org/CodeSystem/discharge-disposition

Encounter Location:
SNOMED
HSLOC

https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
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
Supporting Artifacts 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:
https://fhir.cerner.com/millennium/r4/encounters/encounter/
https://open.epic.com/Interface/FHIR
https://mydata.athenahealth.com/fhirapidoc

Links:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
https://ecqi.healthit.gov/ecqms

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
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 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.

Links: https://ecqi.healthit.gov/qrda
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7
https://www.healthit.gov/isa/support-a-transition-care-or-referral-another-health-care-provider
https://confluence.hl7.org/display/FHIR/2020-09+Clinical+Reasoning


https://ecqi.healthit.gov/qrda
Potential Challenges
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

Comment

Submitted by maria.michaels… on

MedMorph's support of Encounter Diagnosis

The MedMorph project supports the addition of Encounter Diagnosis to USCDI V2. We propose a change to the definition to read: "The diagnoses associated with the encounter, represented by diagnoses codes." This will support implementations by identifying the respective terminologies for these diagnoses codes.

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