Information that guides treatment of the patient and recommendations for future treatment.

Data Element
Clinical Decision Support Data
Description

Data and reporting used for risk stratification, optimization of patient outcomes, detection of decompensation, clinical and patient education.
Submitted By: Grace Cordovano / Enlightening Results
Data Element Information
Use Case Description(s)
Use Case Description Under HIPAA's Right of Access (45 CFR § 164.524 https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html), individuals have a right to access PHI in a “designated record set, where the designated record set is defined as a group of records maintained by or for a covered entity comprising:
1) Medical records and billing records about individuals maintained by or for a covered health care provider;
2) Enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
3) Other records that are used, in whole or in part, by or for the covered entity to make decisions about individuals.

Clinical decision support systems (CDSS) and AI-assisted decision-making have become more integrated into patient care, medicine, and healthcare due to Meaningful Use. If CDSS and AI-assisted decision-making may be used to guide patient care, patients should have a right to a copy of the information used to guide their care. This is especially important for continuity of care, for when patients are denied care, treatments, procedures (either by their payor or clinical care team). Patients should have a right to a copy of any CDS data that is generated and used to guide their clinical care, from a right of access standpoint as well as from the point of transparency.
Estimate the breadth of applicability of the use case(s) for this data element Unknown
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) SNOMED CT
https://confluence.ihtsdotools.org/display/DOCCDS/1.+Introduction
Additional Specifications https://www.hl7.org/implement/standards/product_brief.cfm?product_id=334

https://www.healthit.gov/isa/sharable-clinical-decision-support
Current Use In limited use in production environments
Supporting Artifacts https://www.healthit.gov/isa/sharable-clinical-decision-support
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) Unknown
Restrictions on Use (e.g. licensing, user fees) Unknown
Privacy and Security Concerns The privacy and security concerns about this data element is not unique to this particular type of PHI, thus covered by HIPAA and other governance.
Estimate of Overall Burden Unknown
Other Implementation Challenges Unknown
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 0 - Data element is captured, stored, or accessed in limited settings such as a pilot or proof of concept demonstration.
Criterion #3
Maturity - Current Exchange		 Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 1 - Use cases apply to several care settings or specialties.

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