Clinical Notes for Newborn

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

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

Description

"Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge."

Submitted By: Nedra Garrett / Centers for Disease Control and Prevention
Data Element Information
Use Case Description(s)
Use Case Description	"Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to provide timely and relevant data beyond its use by health care providers. EHR data, if made more available for public health professionals and researchers, can lead to new innovations and can help rapid reporting for birth information reporting. The details of a delivery found within clinical notes for a newborn are crucial for providing the best possible post-natal care to the mother and infant. As well, after delivery, public health needs to capture this data as part of birth certification and fetal death reporting. In particular, birth certification forms the basis of the patient census required by a large number of other public health programs including newborn screening, birth defect reporting and immunization registries making it critical that birth certification is as automated, timely and accurate as possible."
Estimate the breadth of applicability of the use case(s) for this data element	Every year there are approximately 3.7 million births in the United States. Consumption of this data is widespread. Every jurisdiction in the country captures birth certification information and immunization administration. Most also capture birth defects and fetal deaths. Healthcare systems which provide care for expectant mothers should be collecting this data.
Link to use case project page	https://www.cdc.gov/nchs/nvss/births.htm
Healthcare Aims	Improving patient experience of care (quality and/or satisfaction) Improving the health of populations Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)	"LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 \| Infant is being breastfed at discharge" https://loinc.org/?s=73756-9
Additional Specifications	"Vital Records Common Profiles Library FHIR IG - http://build.fhir.org/ig/HL7/fhir-vr-common-ig/branches/master/index.html Vital Records Birth and Fetal Death Reporting - https://build.fhir.org/ig/HL7/fhir-bfdr/index.html HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320 HL7 CDA® R2 Implementation Guide: Birth and Fetal Death Reporting, Release 1, STU Release 2 - US Realm -https://www.hl7.org/implement/standards/product_brief.cfm?product_id=387 IHE Quality, Research and Public Health Technical Framework Supplement – Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1 - https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf"
Current Use	In limited use in production environments
Supporting Artifacts	"Level 2 – at scale, or in more widespread production use (routinely collected already) on several different EHR/HIT systems. EPIC FHIR APIs for patient, vitals, obstetric details (DSTU2, DSTU3, R4) In production use: EPIC stork module (obstetrics) for birth reporting ONC Interoperability Standards Advisory - Sending Birth and Fetal Death Information to Public Health Agencies" "Facility worksheet information: https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf EPIC stork module (obstetrics) for birth reporting: https://www.epic.com/software#PatientEngagement EPIC FHIR APIs for patient, vitals, obstetric details: https://fhir.epic.com/Specifications?api=932 https://fhir.epic.com/Specifications?api=968 https://fhir.epic.com/Specifications?api=966 BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies" https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf
Extent of exchange	4
Supporting Artifacts	"Level 1 – exchanged between 2 or 3 different EHR/HIT systems This data is exchanged routinely as part of birth certification, fetal death reporting and birth defect reporting, however these workflows typically are executed on paper or via flat files rather than through electronic interoperability. IHE Connectathon integration profiles for BFDR-E (2013 - 2020) HL7 FHIR Connectathon results (Sept 2020): birth and fetal death reporting results testing between electronic birth registration system vendors (FHIR) NACCHO 360X Interoperability Demonstrations for Birth and Fetal Death reporting 2020 between NextGen and two state electronic birth registrations system vendors using FHIR. HIMSS Interoperability showcase (2018 – 2019)" "IHE Connectathon: Found in 'New Search', filter by 'Select an integration profile = Birth and Fetal Death Reporting-Enhanced' https://connectathon-results.ihe.net/view_result.php?rows=company&columns=actor&title=integration_profile FHIR Connectathon: https://confluence.hl7.org/display/FHIR/2020-09+Public+Health+Track https://www.interoperabilityshowcase.org/ BFDR-E in ISA: https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies" https://connectathon-results.ihe.net/view_result.php?rows=company&columns=actor&title=integration_profile
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)	None
Restrictions on Use (e.g. licensing, user fees)	None
Privacy and Security Concerns	No concerns over and above the typically privacy and security considerations associated with any health related data.
Estimate of Overall Burden	These data elements are straightforward in nature and should not present a large burden to implement provided the EHR system is capturing the data as part of caring for the woman.
Other Implementation Challenges	When using FHIR there may be associated costs with development of tools needed to access specific data. Often these costs may be a limitation for states who need to develop tools to access certain data.

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 2 - Data element is 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 1 - Data element is electronically exchanged between two production EHRs or other HIT modules using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability	Level 2 - Use cases apply to most care settings or specialties.

Clinical Notes

Data Element

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