Submitted by dshekhar18 on
Terminal Illness
Recommended to have element for Terminal Illness Staus in this Data Class. This is a matter of interest to Next of Kin, Care Team and can help with Transition and Coordination of Care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Data Element |
Applicable Vocabulary Standard(s) |
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Health Concerns
Health-related issue or worry. (e.g., weight gain, cancer risk) |
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Functional Status
Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use) |
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Disability Status
Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities. (e.g., vision, hearing, memory, activities of daily living) |
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Mental/Cognitive Status
Assessment of a patient's level of cognitive functioning. (e.g., alertness, orientation, comprehension, concentration, and immediate memory for simple commands) |
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Pregnancy Status
State or condition of being pregnant or intent to become pregnant. (e.g., pregnant, not pregnant, intent to become pregnant, unknown) |
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Smoking Status
Assessment of a patient's smoking behaviors. |
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Data Element |
Applicable Vocabulary Standard(s) |
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Health Concerns
Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk. |
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Functional Status
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to bathing, ambulation, and preparing a light meal. |
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Disability Status
Assessments of a patient’s physical, cognitive, intellectual, or psychiatric disabilities. Examples include but are not limited to vision, hearing, memory, and activities of daily living. |
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Mental/Cognitive Status
Assessment or screening for the presence of a mental or behavioral problem. Examples include but are not limited to alertness, orientation, comprehension, concentration, and immediate memory for simple commands. |
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Pregnancy Status
State or condition of being pregnant or intent to become pregnant. Examples include but are not limited to pregnant, not pregnant, and unknown. |
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Alcohol Use
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test and alcohol intake assessment. |
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Substance Use
Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription. Examples include but are not limited to substance use disorder score, and substance use knowledge assessment. |
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Physical Activity
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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SDOH Assessment
Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk. Examples include but are not limited to food, housing, and transportation security. |
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Smoking Status
Assessment of a patient’s smoking behaviors. Examples include but are not limited to pack-years and current use. |
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Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
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Health Concerns
Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk. |
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Functional Status
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG). |
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Disability Status
Assessment of a patient’s physical, cognitive, or psychiatric disabilities. Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS). |
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Mental/Cognitive Status
Assessment or screening for the presence of a mental or behavioral problem. Examples include but are not limited to Confusion Assessment Method (CAM) and Patient Health Questionnaire (PHQ). |
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Pregnancy Status
State or condition of being pregnant or intent to become pregnant. Examples include but are not limited to pregnant, not pregnant, and unknown. |
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Alcohol Use
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test, and alcohol intake assessment. |
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Substance Use
Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription. Examples include but are not limited to substance use disorder score, and substance use knowledge assessment. |
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Physical Activity Status
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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SDOH Assessment
Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk. Examples include but are not limited to food, housing, and transportation security. |
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Smoking Status
Assessment of a patient’s smoking behaviors. Examples include but are not limited to pack-years and current use. |
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Data Element |
Applicable Vocabulary Standard(s) |
|---|---|
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Health Concerns
Health-related issue or worry. Examples include but are not limited to weight gain and cancer risk. |
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Functional Status
Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings. Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG). |
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Disability Status
Assessment of a patient’s physical, cognitive, or psychiatric disabilities. Examples include but are not limited to American Community Survey, Veterans RAND Health Survey, and Patient-Reported Outcomes Measurement Information System (PROMIS). |
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Mental/Cognitive Status
Assessment or screening for the presence of a mental or behavioral problem. Examples include but are not limited to Confusion Assessment Method (CAM) and Patient Health Questionnaire (PHQ). |
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Pregnancy Status
State or condition of being pregnant or intent to become pregnant. Examples include but are not limited to pregnant, not pregnant, and unknown. |
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Alcohol Use
Evaluation of a patient's consumption of alcohol. Examples include but are not limited to history of alcohol use, alcohol use disorder identification test, and alcohol intake assessment. |
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Substance Use
Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription. Examples include but are not limited to substance use disorder score, and substance use knowledge assessment. |
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Physical Activity Status
Evaluation of a patient's current or usual exercise. Examples include but are not limited to frequency of muscle-strengthening physical activity, days per week with moderate to strenuous physical activity, and minutes per day of moderate to strenuous physical activity. |
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SDOH Assessment
Screening questionnaire-based, structured evaluation for a Social Determinants of Health-related risk. Examples include but are not limited to food, housing, transportation security, and health literacy. |
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Smoking Status
Assessment of a patient’s smoking behaviors. Examples include but are not limited to pack-years and current use. |
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Data Element |
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Data Element |
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Comment
Submitted by bradtke on
AAPM&R USCDI_v3 Comments
On behalf of the more than 9,000 physiatrists of the American Academy of Physical Medicine and Rehabilitation (AAPM&R), we appreciate the opportunity to provide feedback on the new data classes and elements in the Draft United States Core Data for Interoperability (USCDI) Version 3.
AAPM&R is the national medical specialty organization representing physicians who are specialists in physical medicine and rehabilitation (PM&R). PM&R physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. PM&R physicians evaluate and treat injuries, illnesses, and disability and are experts in designing comprehensive, patient-centered treatment plans. Physiatrists utilize cutting‐edge, as well as time‐tested treatments to maximize function and quality of life.
We are thrilled to see that Functional Status, Disability Status and Mental Function have been added to the Health Status data class as new data elements. These elements are vital to understanding patients and their goals in rehabilitation. Our main concern is the excruciating slow pace of interoperability within healthcare systems and practices. Mapping out data classes and elements for interoperability is hugely important, however if electronic medical record (EMR) vendors are not making this easy for healthcare systems to adopt, we fear this work will be outdated before it gets put into practice. We believe a firm emphasis on educating stakeholders on the importance and need for interoperability is needed in this space.
Submitted by mrallins on
Health Status
The Regenstrief Institute believes that Health Status is a critical data class to support patient care and health information exchange. We recommend including LOINC® as a terminology standard to capture all data elements associated with Health Status. The Clinical section of LOINC includes an extensive set of concepts related to health status and we also have a mechanism to include additional concepts as needed. We are pleased that USCDI has chosen LOINC codes to represent almost all status and assessment variables. In general, LOINC concepts related to Health Status will represent the question. For example, LOINC would be used to encode a data field “Pregnancy status” (What is the patient’s pregnancy status?) using 82810-3, whereas other terminologies (such as SNOMED CT) could be used to encode the response (“Pregnant”, “Not pregnant”).
Regenstrief also recommends re-naming smoking status to Tobacco Use Status to more effectively reflect other types of tobacco use (e.g. smokeless tobacco, e-cigarette use) that is routinely captured in patient assessments and exchanged in health IT systems. We also recommend adding LOINC as a terminology standard to capture tobacco use status which would include smoking status. As noted previously, the LOINC terminology is ideally suited to encode a data field that asks for a patient’s Tobacco use status, the question (for example, with a code such as 72166-2 “Tobacco smoking status” or 88031-0 “Smokeless tobacco status”). Other terminologies such as SNOMED CT would be best suited to encode the response.
In addition to this, we recommend the addition of a broader data element such as Substance Use status which capture a wider variety of substance use that is routinely captured in patient assessments and exchanged in health IT systems.