Assessments 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, problem, or condition.

Data Element
Pain Assessment
Submitted By: Grace Glennon, on behalf of NCQA / NCQA
Data Element Information
Data Element Description An assessment of a person’s pain, which could include assessment of acute and chronic pain using standardized assessment tools.

Assessments of pain include but not limited to pain severity, interference of pain on activity, and pain impact on mood or sleep using unidimensional or multidimensional assessment tools.
Rationale for Separate Consideration There is currently a pain severity element in the vital signs data class at Level 1. That element is solely focused on pain severity and the associated LOINC code. This submission is broader to capture assessments of pain using standardized assessment tools, including unidimensional and multidimensional assessments. Multidimensional pain assessments assess more than one aspect of pain (more than just pain severity) looking at a person’s pain holistically, examining its impact on the person’s physical and mental health, functionality, and other psychosocial factors. Examples of standardized pain assessments with associated codes include: Brief Pain Inventory (BPI) LOINC 77565-0 and Pain Intensity, Enjoyment of Life, General Activity (PEG) scale LOINC 91147-9.
Use Case Description(s)
Use Case Description Chronic pain is associated with multiple conditions and diseases in people of all ages. Nearly every medical and surgical specialty deals with diseases and conditions associated with chronic pain. Understanding a person’s pain and impact on their daily life is critical for identifying a holistic treatment plan that move beyond just pharmacological approaches. Chronic pain is among the most common reasons people seek out medical care, and it has significant consequences in the U.S. and worldwide (Dahlhamer et al, 2018). It is estimated that in the U.S., 50.2 million adults (20.5%) reported pain on most days or every day (Yong et al, 2021) and 18.7 million adults over the age of 65 (52.9%) reported pain in the last month (Patel et al, 2013). It is estimated that costs attributable to chronic pain in the U.S. range from $560 to $635 billion annually (U.S. Department of Health and Human Services (HHS), 2019).

Inappropriate chronic pain management has been associated with the opioid use problem in the US. A focus on appropriate chronic pain assessment and multidisciplinary management is important.

Assessments of pain are routinely conducted at routine wellness visits, for acute hospital visits, and for specialty care. These assessments are also included in the annual Health Risk Assessments, and routinely captured as part of annual wellness visits. This data is exchanged as part of the care continuum as older adults move across health care settings. Many of the standardized assessments to assess pain, including the Faces Pain Scale and Brief Pain Inventory, are routinely used in care and have associated terminology.
Estimate the breadth of applicability of the use case(s) for this data element (Level 2) – Use cases apply to most care settings or specialties.
Link to use case project page https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
Use Case Description In addition to being collected for routine care, pain assessment information is used in quality measurement, including NCQA HEDIS, to assess the quality of care provided to older adults who may experience pain.

Moreover, there are health care disparities related to pain experience and pain management and treatment. Black Americans are more likely to be undertreated for pain, women are at higher risk for common pain conditions, and chronic pain disproportionally affect those with low socioeconomic status. In order to understand and address equity issues, the data must be collected, exchanged, available and measured.
Estimate the breadth of applicability of the use case(s) for this data element An estimated 65 million Americans are enrolled in Medicare in 2023. It is estimated that in the U.S., 50.2 million adults (20.5%) reported pain on most days or every day (Yong et al, 2021) and 18.7 million adults over the age of 65 (52.9%) reported pain in the last month (Patel et al, 2013).
ONC Priority
  • Address behavioral health integration with primary care and other physical care
  • Mitigate health and health care inequities and disparities
  • Address the needs of underserved communities
  • Address public health interoperability needs of reporting, investigation, and emergency response
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC and SNOMED CT
https://loinc.org/ ; https://www.snomed.org/ ; http://hl7.org/fhir/us/core/
Additional Specifications HL7 FHIR US Core supports exchange of pain assessments and standardized results using either Observation or QuestionnaireResponse profiles.
Current Use (Level 2) Captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer
Extent of exchange (Level 2) Between more than two production EHRs or other HIT modules using available interoperability standards
Supporting Artifacts There have been several projects focused on improving pain management, which starts with the collection, storage and exchange of pain assessment and pain related information.
https://cds.ahrq.gov/cdsconnect/artifact/factors-consider-managing-chronic-pain-pain-management-summary
https://build.fhir.org/ig/cqframework/opioid-cds-r4/

Pain assessments have associated standard terminology (LOINC, SNOMED) and are exchanged via FHIR observations and questionnaire responses; most EHRs at least support exchange of observation information.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No restrictions.
Restrictions on Use (e.g. licensing, user fees) None.
Privacy and Security Concerns Exchange of patient health information should follow HIPPA Privacy Rules.
Estimate of Overall Burden Implementation should be low burden—Clinicians must use the standardized tools available for pain assessment and they must be mapped to the appropriate codes. However, the assessments are done as part of routine care .
Other Implementation Challenges One concern related to the collection and exchange of this information raised by some is a potential unintended consequences to contribute to the Opioid overuse epidemic. However, research indicates that the use of multidimensional pain assessments to assess a patient’s pain allows for a more holistic approach to managing pain, which includes other first line treatment beyond Opioids. Additionally, there are several guidelines that guide appropriate treatment for pain which focus on how pain affects the person in multiple areas of physical, psychosocial and social functioning so that the areas of pain impact and the consequences of pain can be managed and mitigated. The appropriate assessment for presence of chronic pain remains critical to allow for appropriate management and treatment that moves beyond Opioids.
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by rdillaire on

CMS-CCSQ Recommends Advancing Pain Assessment to USCDI

Recommendation:  CMS CCSQ recommends advancing Pain Assessment to Level 2 and include in USCDI v8. CMS CCSQ also recommends updating the description for Pain Assessment to make clear that the data element captures both the assessment conducted and the results of the assessment.

Rationale: 

  1. Lack of standardization of pain assessment data in clinical care: Although pain information is routinely collected in healthcare, the content and methods used to assess pain are not consistently standardized across care settings (e.g., cancer centers)  and populations (e.g., pediatric ICU patients). Existing standardized data often focus on individual aspects of pain, such as severity or interference with activities, rather than consistently representing comprehensive pain assessments. Establishing Pain Assessment as a USCDI data element would provide a common interoperability target for clinically meaningful pain assessment information and results, helping make these data more consistently structured, computable, and shareable across settings.
  2. Pain impacts a large proportion of the US population: Many people across the country experience pain and seek care for pain, making it an important piece of information gathered during clinical encounters. The CDC estimated that among the adult U.S. population about 20% experienced chronic pain in 2019-2021, increasing to about 24% in 2023, and 30-40% experienced limb or back pain in 2019; 8.5% have high-impact chronic pain that impacts 1 or more major life activities. A recent study found that higher pain intensity was associated with increased healthcare utilization, including office visits, emergency department usage, and inpatient admission. 
  3. Pain is intertwined with other conditions: Pain is often associated with or indicative of other conditions, including mental health conditions, cancer, and other comorbidities. Therefore, there is a necessity to capture and share pain data across disciplines and settings.
  4. Better pain assessment --> better pain management --> better patient outcomes: Effective pain management through standardized assessments is key to supporting patient outcomes, especially in the midst of the continuing opioid epidemic, which has been fueled in part by mis- and over-prescribing opioid medications for pain and has led to changes in opioid prescribing practices.
  5. Pain assessments are captured in several terminologies, including:
    1. LOINC: 101603-9 CMS pain assessment panel, 38213-5 FLACC pain assessment panel for children, 103780-3 Pain assessment in advanced dementia
    2. SNOMED CT: Various procedures, such as 225399009 Pain assessment (procedure), 423184003 Adult pain assessment (procedure), and 423401003 Pediatric pain assessment (procedure); various pain assessment scales such as 1284852002 Numeric Pain Rating Scale (assessment scale) and the 273593005 | McGill pain chart questionnaire (assessment scale); various ways to capture scale scores such as 443223005 Brief pain inventory score (observable entity) and 1344631005 Pain Assessment in Advanced Dementia scale score (observable entity).
  6. FHIR R4 Symptoms Implementation Guide includes a pain assessment collection and pain assessment score examples, demonstrating how that IG can capture and exchange pain assessment data.
  7. The PACIO Project Personal Functioning and Engagement IG includes a Sensory Functions and Pain Value Set, supporting collection and exchange of pain assessment data.
  8. Current Use and Exchange (Level 2): FHIR R4 APIs for Oracle Health Millennium Platform includes a pain assessment as an example of a service request. Epic includes in their FHIR API Specifications page an example of pain assessments and findings captured in SmartData included in Observation.Search (SmartData Elements) (R4). Atrium Health and MultiCare use SeamlessMD to collect patient-reported outcomes, including pain – “Through the integration of SeamlessMD and Epic, using SMART on FHIR and HL7v2 feeds, providers can easily enroll patients into SeamlessMD and remotely monitor patients from right within the Epic patient chart.”
  9. Breadth of Applicability (Level 2): Completing pain assessments or using pain assessment findings are key components of patient care across all care settings and all clinician disciplines. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) “requires that standardized patient assessment data elements (SPADEs) be collected across post-acute care (PAC).” To support this, every Medicaid- and Medicare-certified nursing facility is required to collect and report data for pain via the MDS (Section J); there are similar requirements for home health via the OASIS (Section J), long-term care via the CARE dataset (Section J), and inpatient rehabilitation facilities via the IRF-PAI (Section J). There is a CMS Electronic Clinical Quality Measure (eCQM) for “Oncology: Medical and Radiation - Pain Intensity Quantified” (CMS157v14). While there is not a federally-mandated pain assessment requirement for acute care hospitals, there are requirements related to pain assessment and management for accreditation by The Joint Commission accreditation and Accreditation Commission for Health Care (ACHC) (ACHC Standard 16.01.02 “Pain assessment and reassessment”).

Submitted by rdillaire on

CMS-CCSQ Supports the Advancement of Pain Assessment to Level 2

Recommendation:  CMS CCSQ recommends the Pain Assessment element be advanced to Level 2.

Rationale: Upgrading the Pain Assessment data element to Level 2 in the USCDI is crucial for improving care and captured in the International Classification of Functioning, Disability and Health (ICF) where effective pain management is essential for enhancing patient outcomes and quality of life. Additionally, this data is required by CMS for PAC setting quality reporting programs. Comprehensive pain assessment is necessary to ensure tailored and effective care for both acute and chronic pain management. These assessments which include evaluating pain severity, its impact on daily activities, and its effects on sleep and mood, play a critical role in developing individualized care plans. Data elements such as Pain effect on sleep (J0510), Pain interference with therapy activities (J0520), and Pain interference with daily activities (J0350) are already captured and standardized in assessments like the IRF-PAI, MDS, and LCDS, and provide valuable insights into how pain impacts patient functioning and recovery. Elevating Pain Assessment to Level 2 will signal to vendors the importance of capturing this data element in healthcare IT systems and may increase its adoption, thus facilitating better pain management strategies that improve quality of care.

Submitted by rdillaire on

CMS-CCSQ Supports the Advancement of Pain Assessment to Level 2

Recommendation:  CMS CCSQ recommends the Pain Assessment element be advanced to Level 2.

Rationale: Upgrading the Pain Assessment data element to Level 2 in the USCDI is crucial for improving care and captured in the International Classification of Functioning, Disability and Health (ICF) where effective pain management is essential for enhancing patient outcomes and quality of life. Additionally, this data is required by CMS for PAC setting quality reporting programs. Comprehensive pain assessment is necessary to ensure tailored and effective care for both acute and chronic pain management. These assessments which include evaluating pain severity, its impact on daily activities, and its effects on sleep and mood, play a critical role in developing individualized care plans. Data elements such as Pain effect on sleep (J0510), Pain interference with therapy activities (J0520), and Pain interference with daily activities (J0350) are already captured and standardized in assessments like the IRF-PAI, MDS, and LCDS, and provide valuable insights into how pain impacts patient functioning and recovery. Elevating Pain Assessment to Level 2 will signal to vendors the importance of capturing this data element in healthcare IT systems and may increase its adoption, thus facilitating better pain management strategies that improve quality of care.

Submitted by rdillaire on

CMS-CCSQ Recommends the advancement of Pain Assessment to Lv2

Recommendation: CMS CCSQ recommends the Pain Assessment element be advanced to Level 2.

Rationale: Upgrading the Pain Assessment data element to Level 2 in the USCDI is crucial for improving care and captured in the International Classification of Functioning, Disability and Health (ICF) where effective pain management is essential for enhancing patient outcomes and quality of life. Comprehensive pain assessment is necessary to ensure tailored and effective care for both acute and chronic pain management. These assessments which include evaluating pain severity, its impact on daily activities, and its effects on sleep and mood, play a critical role in developing individualized care plans. Data elements such as Pain effect on sleep (J0510), Pain interference with therapy activities (J0520), and Pain interference with daily activities (J0350) are already captured and standardized in assessments like the IRF-PAI, MDS, and LCDS, and provide valuable insights into how pain impacts patient functioning and recovery. Elevating Pain Assessment to Level 2 will signal to vendors the importance of capturing this data element in healthcare IT systems and may increase its adoption, thus facilitating better pain management strategies that improve quality of care.

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