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(Do Terminology bindings agree with what is declared in USCDI)
Design covers USCDI Definition?
USCDI Terminology Present?
(Do Terminology bindings agree with what is declared in USCDI)
Design covers USCDI Definition?
Allergies and Intolerances
Substance (Non-Medication)
Yes
Yes
Yes
Yes
Encounter Information
Encounter Identifier
yes
yes
No terminology required in USCDI
Yes
Facility Information
Facility Identifier
yes
yes
No terminology required in USCDI
Yes
Facility Type
yes
yes
No terminology required in USCDI
Yes
Facility Name
yes
yes
No terminology required in USCDI
Yes
Goals and Preferences
Treatment Intervention Preference
IG notes that the 'treatment-intervention-preference' will be added to LOINC. I assume this means the 'system' value under .code is a placeholder and will be fixed to LOINC when the code is available?
GD Comments:
"75773-2" Goals, preferences, and priorities for medical treatment Should be used at Category.code in US Core (used in C-CDA and the AD Guides)
Observation value MS text and codable concept
Confirmed on and found in meeting notes that2023-08-15+Meeting+notesthat the recommendation of LOINC is associated with the category or question. Other codes systems are allowed (for example) SNOMED as the answers
Treatment Intervention Prefences (if found in the EHR) are often text (and not often encoded in EHRs) and in US Core should (start) to be queried for by looking for "75773-2" Goals, preferences, and priorities for medical treatment category code
The actual Preference would be found most likely in text at observation.value
The IG also notes that implementers can include additional codes where appropriate (in .code or .category), however it is unclear where these codes would go. The system and code elements of the coding are fixed, is the intent that any additional codes would go in the text element of the codeableConcept?
US Core and C-CDA reuse Gravity which uses SNOMED for Goals
Goals are often text (and not often encoded in EHRs) and should be queried for by looking for MoodCode GOL or "8689-2 "History of Social function" @observation.code (which is LOINC)
Treatment Intervention Preference
LOINC is used at Observation.code "75773-2" Goals, preferences, and priorities for medical treatment
Confirmed on and found in meeting notes that2023-08-15+Meeting+notesthat the recommendation of LOINC is associated with the category or question. Other codes systems are allowed (for example) SNOMED as the answers
Treatment Intervention Prefences (if found in the EHR) are often text (and not often encoded in EHRs) and in C-CDA should (start) to be queried for by looking for "75773-2" Goals, preferences, and priorities for medical treatment
The actual Preference would be found most likely in text at observation.value
unclear
Care Experience Preference
Similar issue as above: The IG notes that implementers can include additional codes where appropriate (in .code or .category), however it is unclear where these codes would go. The system and code elements of the coding are fixed, is the intent that any additional codes would go in the text element of the codeableConcept?
US Core and C-CDA reuse Gravity which uses SNOMED for Goals
Goals are often text (and not often encoded in EHRs) and should be queried for by looking for MoodCode GOL or "8689-2 "History of Social function" @observation.code (which is LOINC)
Care Experience Preference
LOINC is used at Observation.code "95541-9" Care Experience Preference
Confirmed on and found in meeting notes that2023-08-15+Meeting+notesthat the recommendation of LOINC is associated with the category or question. Other codes systems are allowed (for example) SNOMED as the answers
Care Experience Prefences (if found in the EHR) are often text (and not often encoded in EHRs) and in C-CDA should (start) to be queried for by looking for "95541-9" Care Experience Preference
unclear
Health Status Assessments
Alcohol Use
yes
yes
Substance Use
yes
yes
Physical Activity
yes
yes
Laboratory
Result Unit of Measure
The IG provides guidance about "Using UCUM codes in the Quantity datatype". The guidance begins by saying some quantity types are bound to UCUM, however the quantity type in this profile is not bound to UCUM. Should it be bound to UCUM? Does the guidance still apply in cases where a quantity type is not bound to UCUM?
yes
yes
Result Reference Range
Profile doesn't appear to have any guidance indicating that implementers should use UCUM for this element.
Template doesn't appear to have any guidance indicating that implementers should use UCUM for this element.
yes
Result Interpretation
yes
yes
yes
yes
Specimen Source Site
yes
yes
yes
Members of Specimen type 2.16.840.1.113762.1.4.1099.54concatenate Specimen Type and Specimen Source Site
Specimen Identifier
yes
yes
No terminology required in USCDI
Specimen Condition Acceptability
yes
yes
yes
yes
Medications
Medication Instructions
yes
yes
No terminology required in USCDI
yes
Medication Adherence
no?
no?
Procedures
Performance Time
yes
USCDI definition references medication administration...should the USCDI table point to an appropriate profile?