| | QA - ONC Assessment of Ballot Design in US Core | QA - ONC Assessment of Ballot Design in C-CDA |
Category | Fields | USCDI Terminology Present? (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 |
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| Substance (Non-Medication) | Yes | Yes | Yes | Yes |
Encounter Information |
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| Encounter Identifier | yes | yes | No terminology required in USCDI | Yes |
Facility Information |
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| 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 |
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| 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 that 2023-08-15+Meeting+notes that 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? |
| Goal obs SHOULD use LOINC GD Comments: - Generic (aka) Patient Goals (including SDOH goals):
- USCDI Requires SNOMED OR LOINC
- 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 that 2023-08-15+Meeting+notes that 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? |
| Goal obs SHOULD use LOINC - Generic (aka) Patient Goals (including SDOH goals):
- USCDI Requires SNOMED OR LOINC
- 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 that 2023-08-15+Meeting+notes that 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 |
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| Alcohol Use |
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| yes | yes |
| Substance Use |
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| yes | yes |
| Physical Activity |
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| yes | yes |
Laboratory |
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| 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 2.16.840.1.113762.1.4.1099.54 concatenate Specimen Type and Specimen Source Site |
| Specimen Identifier | yes | yes | No terminology required in USCDI |
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| Specimen Condition Acceptability | yes | yes | yes | yes |
Medications |
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| Medication Instructions | yes | yes | No terminology required in USCDI | yes |
| Medication Adherence |
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| no? | no? |
Procedures |
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| Performance Time | yes | USCDI definition references medication administration...should the USCDI table point to an appropriate profile? | No terminology required in USCDI | yes |
Vital Signs |
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| yes | yes |
| Average Blood Pressure |
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