NACHC would like to thank the ONC for the opportunity to participate in advancing the US Core Data for Interoperability (USCDI). We recognize the value of USCDI and USCDI+ in advancing clinical data interoperability, standards, and definitions in addressing our challenges with data capture, extraction, analytics, reuse, and workflow. We encourage ONC to push HIT developers and vendors to implement USCDI and its extensions to improve data standardization that supports data extraction, public health reporting and research that informs legislation and regulation. 

The attached document describes in its sections and appendices NACHC’s feedback and reiteration of support for the following data elements in both USCDI+ and USCDIv4 moving forward. New comments external to the document are as follows:

 

1. Pregnancy (class) Pregnancy Status (element) 

USCDI level is incorrect in the list if this is similar to the "Pregnancy Status" data element currently existing in USCDIv3, under the "Health Status Assessments" data class. Need clarification if this is an level 2 pregnancy status data element that is submitted to be under a new data class. 

Indicator that a patient is currently pregnant, not pregnant, or that their pregnancy status is unknown currently, as it relates to potential risks and exposures.

Pregnancy status is suggested to be represented by the following LOINC code: https://loinc.org/82810-3

Pregnancy Status was previously proposed and submitted by NACHC in coordination with ACOG for consideration in both USCDIv1 and USCDIv2. We fully support the previous comments from ACOG, CDC and IMO.  While NACHC agrees that there is a critical need for the pregnancy status data element, the currently submitted concept profile should not ideally be referenced from IPS as the submission is not harmonized with electronic case reporting (eCR) LOINC code for pregnancy status (LOINC 82810-3) with SNOMED-CT terminology bindings. The pregnancy status LOINC code that should be referenced is missing or not immediately transparent from the published USCDIv3. We appreciate the use case for reported pregnancy status in a patient-facing survey; however, for use in electronic health record systems (EHRs), we believe the intended concept should preferentially be the presence of a confirmed pregnancy status referenced by LOINC 82810-3, with its terminology bound answer codes (LOINC LL4129-4). This code is referenced in the federally supported Family Planning Annual Report (FPAR) program and data system from HHS, which we believe should be included as a reference in the version 3 draft proposal. NACHC is supportive of ACOG’s position supporting HL7’s CCDA “Pregnancy Status” and related women’s health data elements as its own data class listed in Appendix C in the attached document. 

2. Patient Demographics - Birth Sex

For Male and Female, HL7® Version 3 Value Set: http://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.113883.1.11.1

LOINC: 76689-9 = Sex assigned at birth

Also consider:
99501-9 = Sex for clinical use Patient Type Pt Nom
46098-0 = Sex Patient Type Pt Nom
21840-4 = Sex Patient Type Pt Nom NAACCR v.11
74698-2 = Sex [AHRQ]

3. Patient Demographics - Deceased

NACHC is supportive of a standards-based concept of death; 

We recommend modifications in this element to specify adherence to a clinical terminology standard such as LOINC and SNOMET-CT to represent the concept of Death.

NACHC suggests the use of the LOINC code 80616-6 as the appropriate term due to its use in federal programs for death reporting and certification.
 
It should be noted that the FHIR profile referenced in comment for DeathCertification, for example, references SNOMED-CT concepts (SCT 419099009) and not LOINC and it is expected that the USCore profile would reference the LOINC code for both patient deceased and date of death (LOINC 81956-5, 81954-0).

 

SDOH Section

Veteran Status:
Veterans face unique health challenges arising from their military service. While in service, they face deadly occupational hazards, and upon return, face issues with mental health and reintegration, among other issues. As such, veterans are at heightened risk for certain health outcomes, including Post-Traumatic Stress Disorder and joint replacement surgery.

Z56.82 Military deployment status

Farmworker Status:
Migrant, Seasonal, and Agricultural Workers’ health is impacted by the convergence of multiple factors, including mobility and temporality of work, occupational hazards and harsh working conditions, cultural and linguistic barriers, and immigration status, among others. Access to affordable and appropriate health care is often rare. As a result, migrant, seasonal, and agricultural workers are at high risk for many clinical, non-clinical, and communal health needs.

ICD-10-CM:
Z57.2 Occupational exposure to dust
Z57.3 Occupational exposure to other air contaminants
Z57.4 Occupational exposure to toxic agents in agriculture
Z57.6 Occupational exposure to extreme temperature
Z57.8 Occupational exposure to other risk factors

SNOMED-CT:
106390009 Agricultural/animal husbandry worker (occupation)

Refugee Status:
Refugees are at serious risks for being underserved medically. They additionally survey from an amalgamation of other SDOH such as language barriers, housing instability, occupational risk
Health care providers need to be aware of, and sensitive to, cultural diversity, life situations, and other various factors that shape a person’s identity to provide safe and quality care to all patients. These factors include refugee status, among other factors. (CDC, Cultural Diversity and Considerations)

Refugee family (social concept) - SNOMED: 413323004
Refugee (person) - SNOMED: 446654005
Are you a refugee? - LOINC: 93027-1
Refugee - LOINC: LA29153-6

 

NACHC supports Upsteam's comments regarding reproductive health screening tools and intrauterine devices and implantable devices. See the following:

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 2020, there were 75 Title X grantees with a network of 3,031 clinical service sites that provided care to over 1.5 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 must also highlight that intrauterine devices (IUDs) and the contraceptive implant are currently omitted from USCDI’s list of implantable medical devices. The omission of these contraceptive devices from USCDI’s medical device list represents a surprising gap that must be addressed in the next round of updates.