Care Team Members

ANI's comment on USCDI draft v7: Care Team Members

The Alliance for Nursing Informatics (ANI) strongly supports the addition of Healthcare Agent to the Care Team Members data class, recognizing it as among the most clinically impactful proposals in Draft v7. The ability to identify and rapidly contact a legally authorized healthcare decision-maker, particularly during emergent situations, is a core nursing responsibility that is currently hampered by the lack of structured, interoperable data on this role. We note, however, a concern regarding the use of the term "agent" in this context. As AI-enabled systems, autonomous software agents, and agentic workflows become increasingly prevalent in health information technology, the term "agent" risks semantic confusion in implementation contexts where it may be interpreted as referring to an AI agent rather than a human proxy. ANI recommends that ONC consider the term "healthcare proxy" or similar unambiguous language in implementation guidance and value set documentation to preserve clarity as the terminology landscape evolves. We also recommend that systems capturing Healthcare Agent data include structured fields for contact information, scope of authority, and activation status to ensure this element delivers its full clinical utility, particularly in palliative care and intensive care settings.

Care Team Member Class Comments

APTA thanks ONC for adding “care team member name,” “care team member role,” and “care team member identifier” as data elements.

We recommend that the “care team member identifier” be optional, as not all health care professionals have an NPI, and the data type should/would allow you to send multiple IDs (NPI, DEA number, local, etc.).

provider identifier and provider name

The CDC Division for Heart Disease and Stroke Prevention and the Million Hearts® 2022 Hearts national initiative (co-led by and the Centers for Medicare & Medicaid Services) uses this data as it is available for monitoring and evaluation to prevent 1 million heart attacks and strokes in 5 years. Furthermore, the CDC plans to leverage this data further in the future for surveillance and epidemiology studies if advanced through policy and available from EHRs. The Multi-state EHR-based Network for Disease Surveillance (MENDS) pilot will use electronic health record (EHR) data collected in clinical settings leading to a real-time, chronic disease surveillance model to plan and evaluate short-term outcomes of policies and program interventions.This field is for general comments on this specific data class. To submit new USCDI data classes and/or data elements, please use the USCDI ONDEC system: https://healthit.gov/ONDEC

USCDI_Version_2_Draft_Template for Comments_DHDSP_MENDS_04.15.2021_1.docx

Clarify Care Team Member

Agree with comments noting that care team members represent different types of individuals (licensed, unlicensed, family, etc.) and that it is confusing to see provider name and ID when many care team members may not fall within the regulatory framework and serve different clinical (e.g. nurse, care manager, etc.) and non-clinical roles (e.g., family members, general caretakers, transportation sources, and clergy). If provider and provider ID must be included in this class, then they should be optional. Consider a data elements for “care team member name” should be added.  In Level 2 for this data class, there is a recommended data element for Provider Role, recommend that the role not be limited to a provider only but be identified as “care team member role”.

Clarify Care Team Member

Agree with comments noting that care team members represent different types of individuals (licensed, unlicensed, family, etc.) and that it is confusing to see provider name and ID when many care team members may not fall within the regulatory framework and serve different clinical (e.g. nurse, care manager, etc.) and non-clinical roles (e.g., family members, general caretakers, transportation sources, and clergy). If provider and provider ID must be included in this class, then they should be optional. Consider a data elements for “care team member name” should be added.  In Level 2 for this data class, there is a recommended data element for Provider Role, recommend that the role not be limited to a provider only but be identified as “care team member role”.

Clinovations GovHealth USCDI Draft V2 Comments: Care Team

Expand Care Team Member definition and align with FHIR resource

• Given that NPIs are not available to many care team members who contribute to patient care, including bedside nurses, therapists, family members, and other caregivers, we recommend making “Provider Identifier” optional. We suggest the use of “Care Team Member Name” and “Care Team Member ID” (if applicable and not required) along with “Care Team Member Role” from Level 2.
  • Relationships and roles for each member of the Care Team should focus on the relationship specific to the patient.
  • It may also be useful to add dates for Care Team members for a period of participation. Care Teams are dynamic and change over time. Previous care team members may no longer be applicable at the present encounter.   
• We suggest consideration of modeling “Care Team Member(s)” using the CareTeam FHIR resource (https://www.hl7.org/fhir/careteam.html), which focuses on all the people, teams, and organizations who participate in the coordination and delivery of care for a single patient or a group. There is an extensive SNOMED value set for relationship roles that could be utilized: https://www.hl7.org/fhir/valueset-participant-role.html.
• We raise the consideration of allowing optional use of “Organization NPI” as an identifier. Use of Organizational NPI may support interoperability in scenarios where care team members in roles such as case management are involved in care, but may not be listed as an individual care team provider. If an organization is listed as part of the care team, external trading partners, such as payers and care coordinators, could use this data to share information via push-based mechanisms (e.g., Direct).

Cerner Corporation USCDI Draft V2 Comments - Care Team Member(s)

Provided below are Cerner's comments on the USCDI draft V2 proposals for the Care Team Member(s) data class. Cerner's full public comments on the USCDI draft V2 have been posted on the USCDI general comments section.

In reference to both the proposed additions to the Care Team data class for USCDI V2 (“Provider Name” and “Provider Identifier”), we note that it is critical to amend the naming convention to remove the explicit reference to “Provider.” This inappropriately implies that care team members are limited to healthcare practitioners whereas the care team concept across the industry is commonly thought to be more expansive to include non-clinical roles such as family members, general caretakers, transportation sources, and clergy. This perspective is reflected in both HL7 FHIR US Core, as well as HL7 CDA C-CDA via use of the Care Team Member Function (2.16.840.1.113762.1.4.1099.30) vocabulary standard. Accordingly, while we support that both proposed elements be adopted in USCDI V2, in addition to the separate recommendations laid out below, they should be adopted as “Care Team Member Name” and “Care Team Member Identifier.”

In consideration of the adoption of the “Care Team Member Name” data element, it would be redundant to maintain the existence of the current “Care Team Member(s)” data element. Therefore, the “Care Team Member(s)” data element should be removed in alignment with the adoption of the “Care Team Member Name” data element.

Regarding the proposed “Provider Identifier” element, in addition to our recommendation that this element be amended to be adopted as “Care Team Member Identifier” it is also appropriate to adopt the National Provider Identifier (NPI) as a standard for the data element. NPIs are well established as the most common identifier for healthcare providers and are also leveraged in both HL7 FHIR US Core as well as HL7 CDA C-CDA. The caveat is that, considering our comment on the more expansive definition of care team members (i.e., not isolated to only healthcare providers), it is important to set realistic boundaries and expectations for following the standard. Although it is technically feasible for non-healthcare providers/organizations to obtain an NPI, this is not a common practice and it would be inappropriate to establish an expectation that NPIs be obtained and exchanged for non-healthcare provider care team members. Therefore, we recommend adopting the NPI standard with a specific clarification that it only applies for care team members who qualify as a health care provider as defined under 42 U.S.C 300jj (https://www.law.cornell.edu/uscode/text/42/300jj). Finally, we note that as other identifier types may be used for different care team members, we recommend to also include identifier type.  While in some of the HITAC USCDI Taskforce discussions the notion of an identifier version was raised, we submit that the identifier type is more relevant while a version would be reflected in the type where necessary.

Finally, while it has not been formally proposed as part of the draft USCDI V2, a data element for “Care Team Member Role” is key to the Care Team data class and should be adopted as part of USCDI V2 (there is a current Level 2 data element for “Provider Role”). Even above the need for exchanging a reliable identifier for care team members, it is critical to positively identify the role that those members play within the particular care team. This is especially true given the fact that care team members, as discussed above, consist of a wide range of actors not limited to healthcare providers.

It is appropriate to move forward with adopting this data element as part of the Care Team data class for USCDI V2 even though it was not included in the V2 draft given its current adoption in both HL7 FHIR US Core and HL7 CDA C-CDA. Both standards specifically reference the Care Team Member Function vocabulary standard for defining member roles within the care team, thus we also recommend that this be adopted as the vocabulary standard for the “Care Team Member Role” data element. To that point, it is also critical that this data element be explicitly defined as the specific responsibility of the individual within the care team, which aligns with HL7 FHIR US Core’s CareTeam.participant.role attribute, as opposed to the role that a practitioner may perform at an organization independent of their role within the care team, which would align with HL7 FHIR US Core’s CareTeam.particpant.member attribute when referencing PractitionerRole Profile. This is important because the role or job that the individual performs at an organization may not always be relevant to the actual role they are playing for the patient’s care team. In context of the Care Team data class, the member’s explicit role within the patient’s care team must be the priority and focus.

Patient and other individuals are part of a care team too

Patient name and Related Person Name also need to be included as data elements within the care team members data class.

The intent is that Care Team…

The intent is that Care Team Members (the data class) capture a broad range of people (licensed, unlicensed, family, etc.) involved in that patient's care. However, it is redundant and confusing to list both Care Team Members and Providers, as providers can be considered Care Team Members, or providers can be facilities or organizations. If the intent is that the data class capture each health care professional involved in the delivery of patient care, we would suggest that the data elements be renamed and simplified to:

• Care Team Member Name (with credentials)
• Care Team Member ID (this should be optional, as not all health care professionals have a NPI, and the data type should/would allow you to send multiple ids...NPI, DEA number, local, etc.).

We also recommending adding this data element (currently in Level 2):

• Care Team Member Role (relationship between the Care Team Member and a particular patient)

Clarifying provider vs care team member

The Draft USCDI V2 added two new data elements Provider Name and Provider Identifier. It is unclear how relate to the other existing data element Care Team Members. Clearly providers are members of the care team, so there is overlap in meaning. The Data Class description doesn't hint at what the intended significance might be, but the term "provider" has a wide range of legal, regulatory, and colloquial meanings. In the context of USCDI, the distinctions of a person's credentials, roles, etc. would best be handled as other attributes (some of which can derived from the data linked to the identifier).

Therefore, I recommend simplifying the Data Elements in this Class down to only two for now: Care Team Member Name and Care Team Member Identifier.

Many, but not all, care team members will have an identifier (e.g. an NPI). Thus, we should consider Care Team Member Identifier as a "must support" data element: send it if you've got it, but would not be required in every instance since not every person will have one.

Last, the data class should add a clarifying statement about whether organizations are specifically excluded from being represented here. The definition seems clear that it is about "specific person(s)" but since the NPI, for example, can represent either organizations or individuals, the extra clarity would be useful.