Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 

Data Element
Clinical Notes for Newborn
Description

Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge.
Submitted By: Adam Bazer, MPD / Integrating the Healthcare Enterprise USA (IHE USA)
Data Element Information
Data Element Description Clinical notes information for a newborn may include the Labor and delivery summary
record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge.
Use Case Description(s)
Use Case Description Monitoring disease and making decisions about public health threats depends on accessible and accurate data. EHRs are a data source with potential to provide timely and relevant data beyond its use by health care providers. EHR data, if made more available for public health professionals and researchers, can lead to new innovations and can help rapid reporting for birth information reporting.

The details of a delivery found within clinical notes for a newborn are crucial for providing the best possible post-natal care to the mother and infant. As well, after delivery, public health needs to capture this data as part of birth certification and fetal death reporting. In particular, birth certification forms the basis of the patient census required by a large number of other public health programs including newborn screening, birth defect reporting and immunization registries making it critical that birth certification is as automated, timely and accurate as possible.
Estimate the breadth of applicability of the use case(s) for this data element Every year there are approximately 3.7 million births in the United States. Consumption of this data is widespread. Every jurisdiction in the country captures birth certification information and immunization administration. Most also capture birth defects and fetal deaths. Healthcare systems which provide care for expectant mothers should be collecting this data.
Link to use case project page https://www.cdc.gov/nchs/nvss/births.htm
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC codes exist for each of the proposed data elements

The clinical notes of an new born should capture information such as:
73756-9 | Infant is being breastfed at discharge

https://loinc.org/?s=73756-9
Additional Specifications Vital Records Common Profiles Library FHIR IG - http://build.fhir.org/ig/HL7/fhir-vr-common-ig/branches/master/index.html
Vital Records Birth and Fetal Death Reporting - https://build.fhir.org/ig/HL7/fhir-bfdr/index.html
HL7 Version 2.6 Implementation Guide: Vital Records Birth and Fetal Death Reporting, Release 1 STU Release 2 - US Realm https://www.hl7.org/implement/standards/product_brief.cfm?product_id=320

HL7 CDA® R2 Implementation Guide: Birth and Fetal Death Reporting, Release 1, STU Release 2 - US Realm -https://www.hl7.org/implement/standards/product_brief.cfm?product_id=387
IHE Quality, Research and Public Health Technical Framework Supplement – Birth and Fetal Death Reporting-Enhanced (BFDR-E) Revision 3.1 - https://www.ihe.net/uploadedFiles/Documents/QRPH/IHE_QRPH_Suppl_BFDR-E.pdf
Current Use In limited use in test environments only
Supporting Artifacts "Level 2 – at scale, or in more widespread production use (routinely collected already) on several different EHR/HIT systems.

EPIC FHIR APIs for patient, vitals, obstetric details (DSTU2, DSTU3, R4)

In production use:
EPIC stork module (obstetrics) for birth reporting

ONC Interoperability Standards Advisory - Sending Birth and Fetal Death Information to Public Health Agencies"


https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies
https://www.epic.com/software#PatientEngagement
https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf
Extent of exchange 4
Supporting Artifacts Level 1 – exchanged between 2 or 3 different EHR/HIT systems

This data is exchanged routinely as part of birth certification, fetal death reporting and birth defect reporting, however these workflows typically are executed on paper or via flat files rather than through electronic interoperability.

IHE Connectathon integration profiles for BFDR-E (2013 - 2020)

HL7 FHIR Connectathon results (Sept 2020): birth and fetal death reporting results testing between electronic birth registration system vendors (FHIR)

NACCHO 360X Interoperability Demonstrations for Birth and Fetal Death reporting 2020 between NextGen and two state electronic birth registrations system vendors using FHIR.

HIMSS Interoperability showcase (2018 – 2019)

https://www.healthit.gov/isa/reporting-birth-and-fetal-death-public-health-agencies
https://www.epic.com/software#PatientEngagement
https://www.cdc.gov/nchs/data/dvs/facility-worksheet-2016-508.pdf
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) none
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns No concerns over and above the typically privacy and security considerations associated with any health related data.
Estimate of Overall Burden These data elements are straightforward in nature and should not present a large burden to implement provided the EHR system is capturing the data as part of caring for the woman.
Other Implementation Challenges When using FHIR there may be associated costs with development of tools needed to access specific data. Often these costs may be a limitation for states who need to develop tools to access certain data.


Comment

Submitted by CDC_DSMH_WG on

CDC's comment on behalf of NACCHO for USCDI v5

Hospital systems are not collecting this consistently or reporting it using standard terminology. This should first become a requirement of the EHR Certification standard (if not already), then work must be done with health systems to have this information be collected in a standard format before including it in USCDI.Hospital systems are not collecting this consistently or reporting it using standard terminology. This should first become a requirement of the EHR Certification standard (if not already), then work must be done with health systems to have this information be collected in a standard format before including it in USCDI.Hospital systems are not collecting this consistently or reporting it using standard terminology. This should first become a requirement of the EHR Certification standard (if not already), then work must be done with health systems to have this information be collected in a standard format before including it in USCDI.

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