Health Status Assessments

NCQA and PACIO Recommendation: Health Status Assessment Class

Recommendation

National Committee for Quality Assurance (NCQA) and the PACIO (Post-Acute Care InterOperability) Project* jointly recommend that USCDI clarifies the scope of the Health Status Assessment data class to include both the assessment (LOINC) and the result or answer of that assessment (LOINC answer codes, SNOMED CT, or quantitative result). Currently in USCDI v7, it is unclear among the Health Status Assessment data class’s data elements whether both the assessment and the result/answer are required, whereas this distinction is clear in other data classes (e.g., Vital Signs, Allergies and Intolerances). Specifically, we recommend:

• Updating the data class definition: Information about assessments completed and their results is of critical importance for patients, their authorized representatives, and their healthcare providers because both are needed to identify a condition, need, and/or follow-up care.
• Allowing for both the assessments and their results to be captured: Based on how other data classes accommodate for both types of information, we recommend one of two approaches for USCDI v8 (see the attached PDF for the methods we used to identify these options): 

1. Data element represents both assessments and results: Definitions for data elements within the Health Status Assessment data class should include capture of both the assessment completed and the result(s) and that LOINC and SNOMED be cited as an applicable vocabulary (approach used for Vital Signs data class).
2. Create a data element for results: Existing data elements would capture the assessments completed and a new, results-specific data element that could be applied to any assessment across all data elements would be added with LOINC and SNOMED vocabularies (approach used for Allergies and Intolerances data class).

Rationale

For patient care, care coordination and quality measurement across care settings, knowing that both the health status assessment occurred and the result of that assessment is critical for making care decisions, determining any additional testing, diagnoses, procedures or interventions (i.e., education) that may be required, and for reimbursement. While the completion of a health status assessment does not always result directly in a diagnosis or procedure represented by other USCDI/USCDI+ data elements, the results of health status assessments are used in conjunction with other data related to the patient to guide care. The clarification of scope of this data class to include both the assessment and its result will support consistent implementation and exchange of critical data for patient care across a large breath of care settings. 

In addition, supporting the capture of both assessments and their results, as supported by the IMPACT Act and its push to support standardized patient assessment data, has the potential to support acute and post-acute (PAC) providers and facilities in identifying health issues, reducing unnecessary repeat assessments, supporting care coordination, and improving patient safety and quality of care, as documented in a systematic review and its complementary update, interviews with clinicians, and AHRQ funded demonstration projects. Supporting clear capture of assessments and their results also aligns with current CMS data gathering methods, as viewable in their MDS data explorer that synthesizes facility-provided data about assessments and their results/outcomes.

USCDI Level Criteria

Current standards: Both assessment information and results are covered across various standards.

• FHIR standard: Health Status Assessments and results are captured by US Core Observation profile(s). These profiles require a code for the assessment itself, and require (must have or must support) a result value; These data should be routinely captured and exchanged with the assessment itself. Below is a table with how US Core captures assessment and result information:

• CMS requirements: Data capture and transmission practices for health status assessments with results are required in post-acute care (PAC) settings. In order to receive Medicare reimbursement from CMS, PAC facilities are required to complete specific standardized assessments, the results of which are reported to CMS as mandated by Congress. 
• NCQA HEDIS: Many NCQA’s HEDIS measures are used for health plan reporting and included in CMS Medicare Advantage Star Ratings, State Medicaid reporting, and other programs that require evidence of a health status assessment and a result to confirm care provided and appropriate follow-up.

Current use: Our recommendation meets Level 2, as both assessments and results are captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.

• Epic allows for capture of information about assessments and their results, including integration of the Patient-Reported Outcomes Measurement Information System (PROMIS) which was demonstrated in a large academic medical center and a comprehensive cancer center. Epic supports capture of assessment information and results through FHIR R4 (e.g., Questionnaire, Questionnaire Response).
  • Oracle Health/Cerner’s documentation explicitly describes capture of both an assessment and the results via FHIR R4.

Current exchange levels: Our recommendation meets Level 2, as there are more than two production EHRs or other HIT modules using available interoperability standards to exchange both assessment and results data.

• Epic allows for use of an API (USCDI Type: Industry-Standard Level 1 API) to retrieve assessment and result information from an outside organization. 
• The R4 APIs for Oracle Health Millennium Platform include the ability to retrieve/exchange assessment information and the results. 
• Medicare- or Medicaid-certified post-acute care organizations are required to regularly submit assessment results to CMS. One example is the Minimum Data Set (MDS), which nursing homes and swing bed providers are required to submit to CMS on a regular basis.

Breadth of applicability: Our recommendation meets Level 2, as use cases for capturing/exchanging both assessment information and results apply to most care settings.

• CMS requires hospitals registered with Medicare to report assessment data, including patient-reported outcomes results.
• All PAC settings are required to collect standardized patient assessment data, including results, as part of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). 
• In FY2027, CMS will be implementing a standardized Inpatient Psychiatric Facility Patient Assessment Instrument (IPF-PAI) as indicated in the Consolidated Appropriations Act of 2023. To support capture and submission of assessment and result data, facilities can use “CMS-developed web application called the Patient Assessment Reporting Interoperability Tool (PARIT) or can submit IPF-PAI data using Application Programming Interfaces (APIs) CMS has built from the Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) specification. This will be the first CMS statutory quality reporting program to use the FHIR standard to support patient assessment data submission.”

* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

NCQA PACIO_Health Status Assessment_USCDIv8.pdf

NCQA recommendation: Health Status Assessment clarification

Recommendation: Clarify the scope of the Health Status Assessment data class to include both the assessment (LOINC) and the result or answer of that assessment (often LOINC answer codes, SNOMED CT, or quantitative result).

o    Update the data class definition: Assessments and results of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, follow-up care or a condition.
o    Update the individual element definitions to include the assessment and result as well as LOINC and SNOMED for applicable vocabulary.
Example: Tobacco Use: Assessment and result of a patient’s tobacco product use behaviors. Applicable Vocabulary: LOINC, SNOMED CT
Example: Mental/Cognitive Status: Assessment or screening and result for the presence of a mental or behavioral problem. Applicable Vocabulary: LOINC, SNOMED CT
 

Rationale: In patient care and quality measurement, knowing that both the assessment occurred and the result of that assessment is critical for care decisions and determining any additional testing, diagnoses, procedures or interventions (i.e., education) that may be required. The completion of a health status assessment does not always result directly in a diagnosis or procedure represented by other USCDI/USCDI+ data elements, but instead the result of health status assessments are used in conjunction with other data related to the patient to guide care. The clarification of scope of this data class will support consistent implementation and exchange of critical data for patient care. Additionally, applying this recommendation would align to the setup of other data classes, including Clinical Tests, Diagnostic Imaging and Laboratory. In NCQA’s HEDIS, we assess both that a specific assessment/screening was completed (i.e. tobacco use or depression screening) and that a result of the assessment/screening is present. The result is often used to assess for appropriate follow-up, which may include rescreening, counseling, or other follow-up interventions. 

NCQA Support for PACIO recommendation: ICF Terminology

NCQA supports the PACIO Project Community recommendation to add ICF terminology to the Mental/Cognitive Status and Functional Status data elements to support capture and exchange of important health status information.

PACIO: Include FCMs in Functional & Mental/Cognitive Status

Data Elements: Functional Status (link) and Mental/Cognitive Status (link)

Data Class: Health Status Assessments (link)

Recommendation: Expand the definitions of Functional Status and Mental/Cognitive Status data elements to include the American Speech-Language-Hearing Association (ASHA) Functional Communication Measures (FCMs) that have assigned LOINC codes.

Rationale: The PACIO Project Community* recommends including Functional Communication Measures (FCMs), in the definitions of the Functional Status and Mental/Cognitive Status data elements to demonstrate the capability in each of these domains for capturing communication specific health information. Inclusion of FCMs would help support patient- and caregiver-centered care as well as patient engagement.

Current Standards

• Background: FCMs were created by the American Speech-Language-Hearing Association (ASHA) and are is “used to describe an individual’s functional abilities over the course of speech-language pathology intervention in a given level of care,” according to an ASHA user guide. Eight FCMs have been endorsed by NQF for use in the Physician Quality Reporting System, including: Attention, Memory, Motor Speech, Reading, Spoken Language Comprehension, Spoken Language Expression, Swallowing, and Writing. Of note, an NQF-endorsed measure “tends to be one that is generally regarded as a high-quality measure” by CMS.
• Practice: FCMs have been designed to support compliance with CMS requirements to “report all outcomes data on all Medicare Part B beneficiaries receiving speech-language services” (ASHA). In 2007, CMS recommended use of the NOMS, which includes FCMs, by speech language pathologists.
• Technical: LOINC includes FCM items, organized within a swallowing panel (99852-6), cognition panel (99788-2), Multi-Modal Functional Communication panel (99828-6), Spoken Language Comprehension panel (99836-9), and Spoken Language Expression panel (99844-3).

Current Use

• Practice: The FCMs are the discipline standard for speech, language, and hearing assessments and are included in the National Outcomes Measurement System (NOMS). The purpose is to support longitudinal collection of speech, language, and hearing data to inform clinical care and support quality service provision (ASHA).
  • Technical: There is a NOMS "SMART on FHIR" app for Epic and Cerner Customers that supports collection of FCM data (NOMS includes FCM items).

Current Exchange

• The NOMS is available via a “SMART on FHIR” app for Epic and Cerner Customers also supports transmission of FCM data via its inclusion in NOMS.
  • The FCM data are captured under both Functional Status and Cognitive Status as part of a published PACIO Personal and Functional Engagement (PFE) FHIR IG STU-2, compliant with US Core 6.1.0. 

Breadth of Applicability 

• FCM data are collected by clinicians, including Speech Language Pathologists (SPLs) and audiologists, across various care settings, including post-acute care settings (ASHA). The FCM is not a required to be collected, but is collected by these specialties to support care (example of FCM usage available via ASHA NOMS data reports for 671,628 adults and 3,967 children ages 3-5).
• FCM data can be electronically submitted to the NOMS system by participating organizations that integrate NOMS into their EHR systems.

Applicable standards: The PACIO Community recommends including FCMs within the Functional Status and Mental/Cognitive Status data elements.

* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

Add ICF to Functional Status and Mental/Cognitive Status

Data Elements: Functional Status (link) and Mental/Cognitive status (link)

Data Class: Health Status Assessments (link)

Recommendation: Add the International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status and Mental/Cognitive Status data elements.

Rationale: The PACIO Project Community* recommends the addition of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status and Mental/Cognitive Status data elements. 

• Background: The ICF was created in 2001 to classify functioning domains as a consequence of health conditions, which are not completely captured by any other codeable concept ontology. The ICF ontology allows data to be categorized as mental, cognitive, and functional factors, as well as health concerns in a machine-readable way.
• Clinical utility: Research suggests that the ICF is useful in supporting clinical care related to functioning, cognition, and addressing health concerns, as demonstrated by evidence of its validation in post-acute physiotherapy, usefulness in assessing long-term psychiatric care, and utility in evaluating a telerehabilitation intervention.
• Support: The ICF has been recommended or endorsed by The National Committee on Vital and Health Statistics (NCVHS) and the American Physical Therapy Association. The American Speech-Language-Hearing Association (ASHA) provides information on how to use the ICF. CMS and the CDC provide guidance on using the ICF.

Current Standards

• The WHO developed the ICF to be ICD complementary, with ICF covering functioning and environmental factors and ICD covering diseases and other health problems. As described by the WHO, “ICF is based on the same foundation as ICD…and share the same set of extension codes that enable documentation at a higher level of detail.”
  • ICF has been mapped to SNOMED.
  • HL7 Terminology v5.0.0 includes an ICF code system.
  • HL7 Terminology v7.0.1 includes an ICF naming system.
• The PACIO Project makes extensive use of the ICF ontology in the Personal and Functional Engagement (PFE) FHIR IG STU-2 as category codes for several profiles. 

Current Use

• All post-acute care (PAC) vendors can collect data pertaining to Functional Status and Mental/Cognitive Status given CMS requirements to collect such data required for PAC facilities to get reimbursement (e.g., Minimum Data Set for nursing facilities, Inpatient Rehabilitation Facility Patient Assessment Instrument [IRF-PAI]); therefore, all vendors have the potential to apply ICF to the volume of Functional Status and Mental/Cognitive Status data already collected.
  • Three vendors have deployed the PACIO PFE IG that integrates the ICF: Global Alliant, Open City Labs, and Patient Centric Solutions. 

Current Exchange

• The ICF-integrated PACIO PFE IG has been used to successfully exchange ICF-coded data during the July 2025 CMS Connectathon applied to the PHQ-9 assessment and January 2026 HL7 Conenctathon applied to the PROMIS-10 measure.

* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

PACIO Recommends ICF as an Applicable Vocabulary Standard

• Data Class: Health Status Assessments
• Data Element: Functional Status, Health Concerns, and Mental/Cognitive Status (V3)
• Recommendation: Add the International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status, Health Concerns, and Mental/Cognitive Status data elements.
• Rationale: The PACIO Project Community* recommends the addition of the International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status, Health Concerns, and Mental/Cognitive Status data elements. No other ontologies meet the needs of post-acute care as ICF can, according to consensus from PFE PAC practitioners within the PACIO community. 
  • The ICF was created in 2001 to classify functioning domains as a consequence of health conditions, which are not completely captured by any other codeable concept ontology. The ICF ontology allows users to precisely categorize information on mental, cognitive, and functional factors, as well as health concerns. It can also build in an additional layer of clinical context which is also machine readable. The overarching ICF domains include body structures, body functions, activities and participation, personal factors, and environmental factors.
  • Extensive guidance has also been created based on the use of ICF as a foundation for using Natural Language Processing models to capture free-text functioning information from electronic health records, specifically in the domains relating to mobility, self-care & domestic life, interpersonal interactions and relationships, and communication & cognition.
• Data Standard: Use of ICF has been recommended or endorsed by The National Committee on Vital and Health Statistics (NCVHS) and the American Physical Therapy Association. The American Speech-Language-Hearing Association (ASHA) provides information on how to use the ICF. CMS and the CDC provide guidance on using the ICF.
  • The PACIO Project makes extensive use of the ICF ontology in the Personal and Functional Engagement (PFE) FHIR IG STU-2 as category codes for several profiles. This information captures both clinician insight and in the case of health concerns, allows patients to relate clinical problems to the way they interact with the world in a discrete and machine-readable way. For instance, a patient that has a problem with the structures in their knee might categorize their concern using concepts that describe their ability to play a sport, exercise, navigate their home, or participate in their community, while their rehab team may use concepts related to the functions and structures of the knee, thus building a more complete picture of the problem and why it is important to the patient.
• Data Exchange: The three largest post-acute care vendors collect data pertaining to Functional Status and Mental/Cognitive Status. The standards for this data collection are being phased in and will be fully implemented within the next year. These initiatives will contribute to the standardization of data elements encompassing the statuses mandated by CMS and contained in Section GG. Functional Abilities of tools represented in CMS’s Data Element Library (DEL).
• * The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

PACIO Recommends ASHA FCMs as an Applicable Vocabulary Standard

• Data Class: Health Status Assessments
• Data Element: Functional Status and Mental/Cognitive Status
• Recommendation: Expand the definitions of Functional Status and Mental/Cognitive Status data elements to include the American Speech-Language-Hearing Association (ASHA) Functional Communication Measures (FCMs) that have assigned LOINC codes.
• Rationale: The PACIO Project Community* recommends including the American Speech-Language-Hearing Association (ASHA) Functional Communication Measures (FCMs) that have been assigned LOINC codes for comprehension and expression, e.g., 99836-9 and 99844-3, in the definitions of the Functional Status and Mental/Cognitive Status data elements to demonstrate the capability in each of these domains for capturing communication specific health information. The FCMs are the discipline standard for speech, language, and hearing assessments and are part of a National Outcomes Measurement System (NOMS) that includes data since initial collection started in 1998 and has been recommended by CMS for use by speech language pathologists in 2007. In 2013, ASHA launched a new version of NOMS to help report functional outcomes to support compliance with CMS requirements to “report all outcomes data on all Medicare Part B beneficiaries receiving speech-language services.” Given the importance of the NOMS, which includes FCMs, in assessing patients with speech and language needs, as well as alignment of NOMS with CMS requirements (along with CMS recommendations to use NOMS), including the definitions of Functional Status and Mental/Cognitive Status would be in line with the data that are already being collected systematically. This would help support interoperability of systems used by organizations already collecting these data. 
• Data Standard: The FCM data are captured under both Functional Status and Cognitive Status as part of a published Personal and Functional Engagement (PFE) FHIR IG STU-2, compliant with US Core 6.1.0.
• * The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

PACIO Recommends ICF as an Applicable Vocabulary Standard

• Data Class: Health Status Assessments
• Data Element: Functional Status, Health Concerns, and Mental/Cognitive Status (Draft V6)
• Recommendation: Add the International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status, Health Concerns, and Mental/Cognitive Status data elements.
• Rationale: The PACIO Project Community* recommends the addition of the International Classification of Functioning, Disability and Health (ICF) as an Applicable Vocabulary Standard to the Functional Status, Health Concerns, and Mental/Cognitive Status data elements. No other ontologies meet the needs of post-acute care as ICF can. The ICF was created in 2001 to classify functioning domains as a consequence of health conditions, which are not completely captured by any other codeable concept ontology. The ICF ontology allows users to precisely categorize information on mental, cognitive, and functional factors, as well as health concerns. It can also build in an additional layer of clinical context which is also machine readable. The overarching ICF domains include body structures, body functions, activities and participation, personal factors, and environmental factors.
• Extensive guidance has also been created based on the use of ICF as a foundation for using Natural Language Processing models to capture free-text functioning information from electronic health records, specifically in the domains relating to mobility, self-care & domestic life, interpersonal interactions and relationships, and communication & cognition.
• Use of ICF has been recommended or endorsed by The National Committee on Vital and Health Statistics (NCVHS) and the American Physical Therapy Association. The American Speech-Language-Hearing Association (ASHA) provides information on how to use the ICF. CMS and the CDC provide guidance on using the ICF.
• The PACIO Project makes extensive use of the ICF ontology in the Personal and Functional Engagement (PFE) FHIR IG STU-2 as category codes for several profiles. This information captures both clinician insight and in the case of health concerns, allows patients to relate clinical problems to the way they interact with the world in a discrete and machine-readable way. For instance, a patient that has a problem with the structures in their knee might categorize their concern using concepts that describe their ability to play a sport, exercise, navigate their home, or participate in their community, while their rehab team may use concepts related to the functions and structures of the knee, thus building a more complete picture of the problem and why it is important to the patient.
• * The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange.