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

Data Element

Portable Medical Order
Description (*Please confirm or update this field for the new USCDI version*)

Provider-authored request for end-of-life or life-sustaining care for a person who has a serious life-limiting medical condition.

Usage note: These are meant to follow a person regardless of when and where such an order might be needed (e.g., hospital, care facility, community, home). There are variations in requirements and names for portable medical orders based on jurisdiction.

Examples include but are not limited to POLST (Portable Medical Order for Life-Sustaining Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and out-of-hospital DNR (do-not-resuscitate).

Comment

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.

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.

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. 

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.”

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.

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.

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. 

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. 

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.

CMS-CCSQ Support for Orders for End of Life Care for USCDI 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 was previously identified as 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 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 information is important for quality improvement, clinical decision support, and care coordination to ensure patients are provided the proper end-of-life care as needed. 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.

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