| Interoperability Standards Platform (ISP)

Data Element

Submitted By: Joel Andress / Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
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 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 nedragarrett_CDC on 2024-04-15

CDC's Comment for draft USCDI v5

CDC supports the use of HSLOC codes but also suggests adding the SNOMED codes.

Submitted by yale-coredQMRoadmap on 2023-04-17

CMS-CCSQ/CDC Joint USCDIv4 Priority: Encounter Location

CDC and CMS recommend that this data element be updated to list the following applicable vocabulary standards on the primary page for the encounter data class and its constituent data elements (see: https://www.healthit.gov/isa/uscdi-data-class/encounter-information):

NHSN Healthcare Facility Patient Care Location (HSLOC): https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html
ServiceDeliveryLocationRoleType (HL7): https://terminology.hl7.org/2.0.0/ValueSet-v3-ServiceDeliveryLocationRoleType.html
SNOMED CT
Place of Service (CMS): https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set

Submitted by JAndress316 on 2021-04-16

Response to Comment on Encounter Location

Suggest changing the definition
The MedMorph project needs the location address for the Encounter. The existing Encounter Location element is pertaining to a location type of Encounter, such as a hospital or ICU ward. Due to the granularity and specificity of the existing Encounter Location element, we recommend that Encounter Location Address be a distinct element. If this recommendation is not accepted, then we suggest the current definition for Encounter Location be revised to include the setting (type) and address for the Encounter Location. We recommend to remove the ", and the period of time spent in that location" since this part of the definition appears to be covered by the Location Associated Time Period element. A proposed definition is: "Identifies the location of the encounter. This should include an address, general location (e.g., hospital), and a location within the healthcare facility (e.g., ICU ward)."

For encounter time, CMS's submission intended to recommend including an encounter date/time, or the date/time the encounter began (i.e. admission date/time for inpatient admissions, date/time for office visit) and date/time when the encounter ended (i.e. hospital encounter discharge date/time). We agree there are many date/times that could be defined, and that are important for different use cases.

Submitted by maria.michaels… on 2021-04-09

Suggest changing the definition

The MedMorph project needs the location address for the Encounter. The existing Encounter Location element is pertaining to a location type of Encounter, such as a hospital or ICU ward. Due to the granularity and specificity of the existing Encounter Location element, we recommend that Encounter Location Address be a distinct element. If this recommendation is not accepted, then we suggest the current definition for Encounter Location be revised to include the setting (type) and address for the Encounter Location. We recommend to remove the ", and the period of time spent in that location" since this part of the definition appears to be covered by the Location Associated Time Period element.

A proposed definition is: "Identifies the location of the encounter. This should include an address, general location (e.g., hospital), and a location within the healthcare facility (e.g., ICU ward)."

Submitted by maria.michaels… on 2020-11-23

MedMorph's need for Place of Birth

Encounter Location by itself is not sufficient. The type of location (e.g. hospital, home, car, etc.) is needed, not just the location. Can the narrative be expanded as “Identifies the location of the encounter, and the period of time spent in that location. This may include a general location (e.g. hospital), as well as a location within the healthcare facility (e.g. ICU ward), and non-hospital physical types such as house or vehicle”

A more fitting label for this element should be 'Birth/Delivery Location Type'. This item is captured on the national standard worksheets for jurisdictions to report a live birth and fetal death. As commented on other birth reporting data elements submitted to USCDI, it is important to recognize that birth and delivery events information may be captured within specific areas of a healthcare system such as labor and delivery summaries and prenatal care records. To help lessen the burden of implementations and queries of these events is the reason to propose a new Delivery and Pregnancy Information class where data elements like Birth/Delivery Location Type may be captured.

National worksheets for reporting of live birth and fetal death:
https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf,
https://www.cdc.gov/nchs/data/dvs/fetal-death-facility-worksheet-2019-508.pdf

Additional relevant specification for this data element includes HL7 and IHE standards listed below.

HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320

IHE Quality, Research and Public Health Technical Framework Supplement – Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1: https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf

Vital Records Common Profiles Library FHIR IG: http://build.fhir.org/ig/HL7/fhir-vr-common-ig/branches/master/index.html

Vital Records Birth and Fetal Death Reporting: https://build.fhir.org/ig/HL7/fhir-bfdr/index.html

Birth Defect Reporting FHIR IG: https://build.fhir.org/ig/HL7/fhir-birthdefectsreporting-ig/index.html

HL7 CDA® R2 Implementation Guide: Ambulatory and Hospital Healthcare Provider Reporting to Birth Defect Registries Release 1 , STU 2 -US Realm: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=428

Below lists examples of artifacts of where this data element is collected.

EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement

EPIC FHIR APIs for patient, vitals, obstetric details:
https://fhir.epic.com/Specifications?api=932
https://fhir.epic.com/Specifications?api=968
https://fhir.epic.com/Specifications?api=966

BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies

Submitted by maria.michaels… on 2020-11-18

MedMorph's need for Encounter Location Address

If this recommendation is not accepted, then we suggest the current definition for Encounter Location be revised to include the setting (type) and address for the Encounter Location. A proposed definition is: "Identifies the location of the encounter. This should include an address, general location (e.g., hospital), and a location within the healthcare facility (e.g., ICU ward)."
We recommend to remove the ", and the period of time spent in that location" since this part of the definition appears to be covered by the Location Associated Time Period element.