Contextual information that provides supporting details for healthcare data.

Data Element

Applicable Vocabulary Standard(s)
Diagnostic Report Date

Date and time a report containing test results or clinical interpretation was made available to providers.
Indication

Sign, symptom, or medical condition that is the reason for a care activity.

Usage note: Indication may be included with a procedure, medication, and an order.
  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
Performance Time

Time and/or date a care activity is performed.

Examples include but are not limited to vaccine and medication administration times, surgery start time, time ultrasound performed, and laboratory specimen collection time.
Reason Not Performed

Explanation or justification provided when an order or practice guideline is not carried out. 

Usage note: Should be included with a procedure, immunization, and medication.

Data Element
Report Date

Comment

Submitted by rdillaire on

CMS-CCSQ Requests Enhancing Healthcare Information Attributes

Recommendation: CCSQ recommends that the mappings between Healthcare Information Attributes data elements and their relevant classes be clearly displayed and linked within USCDI v7.

Rationale: Capturing information that applies to multiple data classes within a single set of data elements under the Healthcare Information Attributes data class without clearly displaying the two-way mappings may create confusion for implementers, as well as for individuals who capture and review the data. These data elements do not uniformly apply across the same set of data classes. As a result, when an implementer is working within a specific data class, such as Procedures, they may overlook relevant information that is instead located under Healthcare Information Attributes. Furthermore, relying on US Core to address the many-to-many mappings among Healthcare Information Attributes data elements may create practical challenges. In the absence of these mappings, it can be difficult to provide precise feedback on USCDI, while feedback received through US Core on the mappings would not be able to inform the already finalized USCDI version retroactively. In practice, US Core is typically updated more than a year after a given USCDI version is released and finalized, which can create a meaningful gap between the publication of USCDI and the resolution of related mapping issues in US Core. For example, USCDI v7, which is the subject of this comment, is not expected to be reflected in US Core until version 10, and work on version 10 has not yet begun. Finally, data class specific contextual information associated with each of the Healthcare Information Attributes data elements may not be captured in either USCDI or US Core.

CCSQ recommends enhancing USCDI v7 to clearly show the relationships between each Healthcare Information Attributes data element and its corresponding data classes. These mappings should be visible on each Healthcare Information Attributes data element page and on each relevant data class page. For example, the page for the Reason Not Performed data element should include direct links to the Medications, Procedures, and Immunizations data classes. Conversely, the pages for the Medications, Procedures, and Immunizations data classes should include direct links back to Reason Not Performed, along with any other applicable Healthcare Information Attributes data elements.

Submitted by csnewman on

Clarify the application of Healthcare Information Attritributes

It is unclear if this data class is simply an "add on" to other data classes like immunization, diagnostic imaging and laboratory? If so, that should be called out in the description  (including a full, normative list of other data class to which these attributes apply) and not just in a Usage Note in Reason Not Performed and Indication (and are these usage notes exemplars or prescriptive?)
Diagnostic Report Date and Performance Time should be aligned in name (why is one "date" and one "time") and description (one is past tense and one is present tense; one uses "date and time" while the other uses "time and/or date")
Is there a scenario where just a time, without a date, would be appropriate for performance time?
The name performance time for a laboratory instance may be confusing as it is clear that the specimen collection date/time is the relevant value, but "performance" evokes the performance of the test on a previously collected specimen

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