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
Functional Status
Description (*Please confirm or update this field for the new USCDI version*)

Assessment of a patient’s capabilities, or their risks of development or worsening of a condition or problem. (e.g., fall risk, pressure ulcer risk, alcohol use)

Applicable Vocabulary Standard(s)

Applicable Standards (*Please confirm or update this field for the new USCDI version*)
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72

View guidance on Applicable Vocabulary Standards and versioning.
Submitted By: Holly Miller, MD / MedAllies
Data Element Information
Data Element Description Assessment is a data class comprised of many tools used clinically to evaluate patient status, risks and capabilities.
Use Case Description(s)
Use Case Description We are proposing “Assessment” as a USCDI data class to serve as a repository for any standardized assessment instrument. There are thousands of assessment instruments in use across clinical settings, public health providers, payors, and researchers.
As one example, the CMS Data Element Library (DEL: Home - Data Element Library (cms.gov)) is an example of multiple standardized data elements used in the federally mandated assessment instruments by LTPAC (Long-Term and Post-Acute Care) providers who collectively provide care to over 7 million Medicare Beneficiaries per year. Because these assessments are required for payment and quality reporting, they are collected by the more than 15,000 Skilled Nursing Facilities (SNFs), 11,000 Home Health Agencies (HHAs), 4,600 Hospice Care agencies, 1,100 Inpatient Rehabilitation Facilities (IRFs), and 400 Long-Term Care Hospitals (LTCHs). These standardized data are collected and submitted to CMS as required by these entities. Most of these data elements are mapped to LOINC and some are mapped to C-CDA templates.
The DEL incorporates only a tiny percentage of standardized assessments currently in use; and the use of standardized assessments is universal in health care.
Estimate the breadth of applicability of the use case(s) for this data element This data class pertains to most or all patients, providers or requestors.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC, SNOMED-CT
https://loinc.org/; https://www.snomed.org/
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden This would vary depending on the specific assessment instrument and how it is used.
Other Implementation Challenges Unknown

Comment

Submitted by suchen on

Functional status with needs beyond post acute care

Functional status assessments are commonly used in healthcare to document a patient’s baseline ability to manage daily routines and life activities. This assessment can be used as an indicator of quality of life (QOL) and help guide delivering patient-centered care. Functional status assessments are used broadly in healthcare, and can be used to:
* screen initially for problems, as well monitor the patient over time
* assess how a disease impacts a patient’s baseline functional status and their overall ability to tolerate certain therapies during serious illness

Functional status assessments can be generic or disease specific. For instance, in oncology, the Eastern Cooperative Oncology Group (ECOG) Performance Status assists in determining a patient’s potential chemotherapy tolerance.

A plethora of functional status assessment tools have been created to assist clinical management and are used broadly in medicine in fields such as oncology, palliative care, surgery, orthopedics, geriatrics, psychiatry, neurology, physical medicine and rehabilitation, nursing, etc. Achieving optimal patient outcomes for health and well-being requires an understanding of factors that affect quality of life (QOL), such as the ability of patients to perform basic activities and participate in life situations.

Please see attachment with similar prior submission regarding need for standardized "functional status" data.

This comment is made on behalf of CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator community of professional medical societies, health systems, industry and others seeking to achieve interoperability via the mCODE (minimal Common Oncology Data Elements) standard in order to drive step-change improvements in cancer patient care and research.

Functional Status Assessment _ USCDI Version 3 Proposal.docx

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