We are grateful to the Office of the National Coordinator for Health Information Technology (ONC) for the opportunity to comment on USCDI+. We believe the USCDI+ data set would be more complete with more robust representation of reproductive health-related data elements, including two widely-used reproductive health screening tools and inclusion of contraceptive implantable device codes. We discussed this opportunity with ONC in March 2023, and we hope these issues will be followed up on.

We represent Upstream USA, a nonprofit that partners with health centers to provide training and technical assistance to improve women’s health, increase access to contraception, and address disparities and biases in contraceptive care. Our transformative, whole-health center approach empowers patients to decide if and when they want to become pregnant, a critical step towards improving maternal health, as well as positive outcomes for parents, children, and their families. 

Upstream has concerns about USCDI+’s the continued lack of inclusion of key contraceptive need screening tools, despite efforts to request reevaluation at higher levels of usage and exchange by clinical care providers and government reporting systems, as well as lack of representation of implantable medical device codes for intrauterine devices and contraceptive implants. Failure to include these codes will hamper the ability of providers and stakeholders to exchange data across EHRs, the ability of researchers to understand the availability and utilization of contraceptive care services, and the ability of federal programs (including Title X) to quantify and report on their critical missions.

Including Reproductive Health Screening Tools in USCDI+ 

A best-in-class workflow for contraceptive care begins with some form of pregnancy intention or contraceptive need screening and includes contraceptive counseling and documentation of contraceptive method provision or use, as desired by patients. Of those data elements, only screenings are not currently included in USCDI or USCDI+. There are two screening data elements included in USCDI at “comment level,” the Pregnancy Intention Screening Question (PISQ) and the Self-Identified Need for Contraception (SINC) screening, both of which we believe meet the criteria reevaluation at higher levels based on current use and exchange of these data elements. 

PISQ is a well-known, person-centered approach to ensure that female patients of reproductive age are offered information and services to help them achieve their desired reproductive goals, including pregnancy prevention or achievement. The PISQ data element has a LOINC code and answer list, and is also included in a LOINC panel for pregnancy information. PISQ is included in the IHE C-CDA profile for FPAR 2.0, which was successfully tested at the 2015 IHE North American Connectathon in Chicago by five EHR vendors. PISQ is also included in the FHIR Implementation Guide and accompanying profiles.

Additionally, the PISQ data element is already part of a federal reporting requirement: the HHS/Office of Population Affairs Family Planning Annual Report 2.0 (FPAR 2.0) for Title X Family Planning Program Grantees. As of 2021, there were 75 Title X grantees with a network of 3,284 clinical service sites that provided care to almost 1.7 million patients of reproductive age.  All Title X grantees will report encounter-level data, including PISQ, beginning with the 2022 reporting period. USCDI describes the “current exchange” of PISQ as being at comment level, while all other aspects are at Level 1 or Level 2. In light of these updated reporting requirements in FPAR 2.0, we believe there is meaningful current exchange of PISQ data.

Beyond its inclusion in the Title X program, PISQ is also included as a data element in the CDC-funded Women’s Health Project to advance Postpartum Care Services, a partnership with the National Association of Community Health Centers and two Health Care Controlled Networks (HCCNs): Alliance Chicago and OCHIN Epic. Participating health centers exchange this data element with their respective HCCN. In addition, working through its health agency partners, Upstream USA has embedded PISQ into at least 15 different vendor systems in WA, MA, RI, and NC. Vendor instances include Epic, Centricity, Intergy, and eClinicalWorks systems. PISQ is also known to be available widely within templates in OCHIN Epic and NextGen.

Lastly, it is important to clarify that pregnancy intention screening is fundamentally different from the Pregnancy Status data element in USCDI, which only captures positive or negative pregnancy findings and not whether the patient had been screened for their desires to achieve or avoid pregnancy.

In addition to PISQ, the SINC screening tool, while newer to the field, also has a standard LOINC code and is part of the federal Title X FPAR 2.0 reporting requirement. This tool is also an essential part of two  eCQMs that have been endorsed for trial use by the National Quality Forum (NQF #3682e, NQF #3699e).

Including Contraceptive Implantable Devices in USCDI+

In addition to requesting that you include these important reproductive health screening data elements in USCDI+, we would also highlight that intrauterine devices (IUDs) and the contraceptive implant are currently omitted from USCDI’s list of implantable medical devices to the best of our knowledge. The omission of these contraceptive devices from USCDI’s medical device list represents a surprising gap that should be addressed in the next round of updates.

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We appreciate your attention to this topic. We would be glad to discuss this further should you desire to learn more. Please contact Emily Decker at edecker@upstream.org if there is any other information we can provide.