Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 

Data Element
Expanded list of clinical notes, detailed in Data Element Description
Description

Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative)
Submitted By: KarenP-SSA / Social Security Administration (SSA)
Data Element Information
Rationale for Separate Consideration This expands the instances of clinical notes available on the USCDI roadmap.
Use Case Description(s)
Use Case Description To assist with disability determination, SSA sends an electronic request and a patient authorization to the healthcare provider’s system via national health data exchange networks. Information is returned within seconds or minutes, rather than the days or weeks it may take when manual methods of requesting medical records are used.

This automation—when sufficient details are provided via the full complement of clinical notes—can result in a significant reduction in the time it takes to make a disability determination, which produces: 1) Faster disability claim determination and quicker benefit payments to patients; 2) Labor savings and payments to providers; 3) Cost efficiencies for US taxpayers.
This request to expand the set of Notes included in USCDI includes:
1) Constrained coding for each (like specified for most of the V1 USCDI Notes);
2) Constraints on where each should appear.
Estimate the breadth of applicability of the use case(s) for this data element Today, SSA requests about 2 million medical records electronically (15-20 million total) from almost 500,000 providers on behalf of 3 million patients annually. The agency plans annual increases in the amount of medical records received electronically.
Link to use case project page https://github.com/SSAgov/HealthIT
Supporting Attachments Suggested LOINC codes and placement for SSA USCDI V2 Clinical Notes proposal final.pdf
Use Case Description Most health information exchange use cases involve clinical notes, and “notes” are indeed
included in much of that exchange, but this information is scattered throughout clinical
documents—some as well-defined “clinical notes and others as observations “sections” in CDA
and various Resource types in FHIR. Many “notes” use using coding from a grab bag of available
values for coding the same information.

Understandably, standardizing functionality around this USCDI addition will not happen overnight,
but (most critically) it will establish the roadmap for standardizing the electronic health information
(EHI) exchanged in order to increase the effectiveness of this information for clinicians, patients,
payers and other stakeholders.

• Key Takeaway: This expanded list of USCDI Clinical Notes, along with constraints
on their coding and placement, defines the roadmap for implementers to use as
they prioritize support of additional clinical notes.
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 tens 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) LOINC—although we would like to see the set of codes constrained as suggested above.
In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability.
https://search.loinc.org/searchLOINC/search.zul?query=Note
Additional Specifications HL7 FHIR® US Core Implementation Guide: Clinical Notes Guidance https://build.fhir.org/ig/HL7/US-Core-R4/clinical-notes-guidance.html

We advocate following the core guidance in this guide:

“All of [USCDI V1] clinical notes SHALL be exposed via DocumentReference.

This requirement is necessary because some systems scan lab reports and do not store them in the DiagnosticReport resource. See FHIR Resources to Exchange Clinical Notes (https://build.fhir.org/ig/HL7/US-Core-R4/clinical-notes-guidance.html#fhir-resources-to-exchange-clinical-notes) for more detail.”

and:
“In order to enable consistent access to scanned narrative-only clinical reports the Argonaut Clinical Note Server SHALL expose these reports through both DiagnosticReport and DocumentReference by representing the same attachment URL using the corresponding elements listed below. Exposing the content in this manner guarantees the client will receive all the clinical information available for a patient and can easily identify the duplicate data.
• DocumentReference.content.attachment.url
• DiagnosticReport.presentedForm.url”
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Many EHR systems support many varieties of Clinical Notes—albeit using multiple variations of the currently unconstraint coding. Adding the additional notes we are requesting—along with the constrained coding--to USCDI will provide the industry with guidance on those constraints and create a roadmap for standardization of this information.
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 Today, SSA receives about 2 million medical records annually from almost 200 partner organizations. The agency plans to continue to increase the amount of medical records received electronically. The ability of those organizations to provide this information is a fundamental screening requirement for participation in our program.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden Implementation burden should be light for implementers already supporting the production and coding of clinical notes. This is adding and/or refining instances and standardizing the coding of existing clinical notes functionality, not creating net-new functionality.
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 0 - Data element is not 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.

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