Procedures

Procedures

1. Procedures. 
   1. In light of the comments on Lab Orders and given some HIT vendors are modeling Laboratory Orders as Procedure elements, it’s requested that clarity and guidance be provided that procedures are not laboratory orders.  It would help ensure that HIT vendors have appropriate functionality for laboratory orders and don’t inadvertently get certified for incorrect functionality for laboratory orders by calling them procedures. It would also help ensure that Laboratory Orders are encoded with LOINC and not SNOMED CT Procedure Hierarchy Codes.

Lantana Consulting Group Comment

The Procedures data class is a broad category that captures medical and dental procedures and interventions that impact the physical person as captured by CDT, CPT, ICD-10-PCS and includes SDOH interventions and Reason for Referral.  We recommend clarifying the scope of the Procedures data class and considering the creation of an SDOH Data Class.

Another gap in USCDI that is closely related to a Referral is a Transition of Care Summary. ONC’s 360X Project is testing the exchange of both referrals and a transition summary. Lantana recommends including both referrals and transition summaries under a Care and Treatment Plan data class.

Rename for specificity

To delineate the element name from the class name, MedMorph suggests renaming the Procedures element to Procedure Code. This modification will more closely align with the USCDI definition of a Data Element ("A USCDI “Data Element” is the most granular level at which a piece of data is exchanged") as well as with US Core.