The American College of Radiology (ACR) would like to thank the Office of the National Coordinator for Health Information Technology (ONC) for the opportunity to provide feedback on the United States Core Data for Interoperability Plus (USCDI+) Quality - Draft Data Element List.  The ACR was founded in 1923, and is at the forefront of radiology evolution, representing more than 41,000 diagnostic and interventional radiologists, radiation oncologists, nuclear medicine physicians and medical physicists.

As the USCDI standard supports interoperable electronic health information and patient care across health systems, the ACR supports the idea of USCDI+ Quality for adapting this framework to include quality measurement data elements. ACR would like to offer the following feedback on the draft data element list.

Level of completeness

While there are general data elements that Diagnostic Imaging, Radiology, and the ACR find useful in reporting of quality measures, the use cases and data elements proposed contain no Diagnostic Imaging components.  Beginning with the time of the order, critical information for reporting quality measures may be gathered.  The service request, which maps to the Orders, Level 2 data element of, Types of orders for medical care/services, provides reason for study in the FHIR Service Request.  This provides information on the appropriateness of the Diagnostic Imaging performed.  Accession number, currently a Level 2 data element, also from the FHIR Imaging Service Request, provides a key reference to the report as well as the images that were generated as a result of the Order.  The images themselves contain critical metadata elements that can only be extracted when an Imaging Reference is present.  The Imaging Reference data element is also a Diagnostic Imaging, Level 2 data element.  This reference allows the metadata information to be obtained using the DICOMweb standard.  Finally, the ACR would see it critical to reporting on quality measures to have the Diagnostic Imaging Report, which has been a part of the USCDI Core since version 2, included in the data elements proposed for USCDI+.  The Diagnostic Report is the work product of the Radiologist and the main communication method between care providers.  This narrative report contains findings, impressions as well as recommendations for continuing patient care that are critical in determining the overall quality of care.  Analysis of these reports are the key to many of the quality measures ACR reports to CMS.

Level of specificity

While there are specific items that are directly mapped to USCDI core elements, which in turn map to FHIR resources, there remains a gap between the FHIR specification and the goal of USCDI+ for use of these quality data elements.  Specifically, the ACR would like to point out that although many FHIR resources have fields that hold the information requested by USCDI and now USCDI+, most if not all the FHIR element ids for critical reporting or resource usefulness are optional in FHIR, thus making the resource less useful or in some cases unusable for the desired purpose.  Pointing to specific element ids within the FHIR resource itself would convey to implementors the importance of including such optional element ids.  Also noting preferred coding schemes for quality data element usefulness should be part of the USCDI+ initiative.  For example, in FHIR resource ServiceRequest, ServiceRequest.reason is optional, although critical for Diagnostic Imaging quality measures and its value is a CodeableReference which can ultimately be free text and not an ICD coded reference which would ultimately make the resource more useful.

Usefulness of companion guidance

The ACR finds the companion guide extremely helpful. We suggest including a column to reference FHIR implementation guides.  As the previous comment on level of specificity suggests, this should also carry down to specific USCDI Core data elements and FHIR element ids.

Frequency of updates

The ACR would like to ensure that a cycle of comment period and publication is followed for USCDI+ as there is with USCDI.  The ACR understands that more flexibility may be needed in this area, but as implementation guides balloting and the FHIR update cycles are significantly longer, quarterly update frequency should be sufficient to ensure reviews and include updates.  Radiology system updates can be extremely involved and expensive to generate, so more frequent than quarterly cycles may not be appropriate in the Diagnostic Imaging area.

The American College of Radiology (ACR) would like to thank the ONC for the opportunity to provide this feedback which the ACR feels is critical to the inclusion of Diagnostic Imaging in the USCDI+ quality efforts.  We offer our experience to the ONC for any further discussions which may be appropriate on this or any other topic.