NCQA Comments on ASTP’s USCDI Draft v6

September 24, 2024

Micky Tripathi, PhD, MPP
Assistant Secretary for Technology Policy
U.S. Department of Health and Human Services
330 C Street SW, 7th Floor
Washington, DC 20201

Dear Dr. Tripathi:

The National Committee for Quality Assurance (NCQA) thanks ASTP for the opportunity to provide recommendations for USCDI version 6.

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving toward an equitable health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.

NCQA is pleased to provide the following recommendations for USCDI version 6, outlined below.

Clinical Notes

1. Discharge Summary Note
   1. Recommendation type: Modification to existing USCDI element.
   2. Recommendation: Update the required components of a discharge summary note to include: practitioner responsible for the care, reason for hospitalization, diagnoses at discharge, procedures or treatment provided (including test results), current medication list, instructions for patient care post-discharge, and pending tests.
   3. Rationale: High-quality discharge summaries are considered essential for promoting patient safety during transitions between care settings. The recommended required components of the discharge summary align to requirements set by NCQA’s HEDIS measure (Transitions of Care) used in CMS Medicare Advantage Stars and aligns to The Joint Commission requirements. Aligning USCDI requirements to industry standards supports reinforcement of high quality discharge summaries to support transitions of care.

Diagnostic Imaging

1. Diagnostic Imaging Test:
   1. Recommendation type: Modification to existing USCDI element.
   2. Recommendation: Update vocabulary standards to include CPT, SNOMED CT, and ICD-PCS in addition to LOINC.
   3. Rationale: These represent vocabulary standards routinely used to capture diagnostic imaging tests, such as CT scans and mammography. This data element should reflect the alignment occurring in the health IT space.
2. Diagnostic Imaging Report
   1. Recommendation type: Modification to existing USCDI element.
   2. Recommendation: The current USCDI element includes both the structured and unstructured components of the report. We recommend adding RadLex and SNOMED CT as appropriate vocabulary standards representing the clinical findings from the structured components of an imaging report.
   3. Rationale: The clinical conclusions or findings resulting from a diagnostic imaging study represent important information to be exchanged via standard terminology to support appropriate follow-up care and care coordination. NCQA is developing measures that require the findings from imaging reports, specifically for mammography and CTs for breast and lung cancer screenings, which routinely represent the clinical findings using the ACR Reporting and Data Systems (RADS).  Adding SNOMED CT and RadLex vocabulary standards to the USCDI element will support interoperable data exchange of these important clinical data.

Goals and Preferences

1. Patient Goal Category (new element submission)
   1. Recommendation type: Add new USCDI element.
   2. Recommendation: Add an additional element to the Goals and Preferences data class to capture patient goal categories, defined as the domain of the stated patient goal. Examples of goal categories include housing, physical function, behavioral, and social & role functioning.  (Vocabulary Standard: HL7 terminology, Goal Category)
   3. Rationale: “Person-centered outcomes” are personalized, structured, measurable goals identified by a person or their care partner around what matters most to them at that time. Sharing of critical patient-centered data across care settings supports prioritization of a person’s well-being rather than just treating symptoms. While individual patient goals are important (and already included in USCDI), sharing of goal categories allows for a high-level understanding of the goal focus and supports population health-level decision making as organizations can better understand what matters most to their clients/consumers and can tailor their funding, focus and services based on these goal categories/domains.

Over the past 10 years, via NCQA’s Person-Centered Outcome Measures work, we have identified 12 high-level goal domains that individuals identify as what matters most to them. NCQA is actively working with the HL7 Patient Care work group to update the HL7 terminology for Goal Category to include additional goal categories aligned to our work. Goal categories support promoting health equity and integrating behavioral health, both stated ASTP priorities for USCDI.

Patient Summary and Plan

1. Care Plan
   1. Recommendation type: Add new USCDI element.
   2. Recommendation: Add Care Plan element to USCDI.
   3. Rationale: Care plans are able to be exchanged via FHIR (https://hl7.org/fhir/R4/careplan.html) and are critical components to high quality, person-centered care and care coordination. NCQA uses care plans in our person-centered outcomes measures to monitor and assess care aligned to the goals defined by the person.

Health Insurance Information

1. Coverage Type:
   1. Recommendation type: Modification to existing USCDI element.
   2. Recommendation: Adjust the data element definition and examples to note that coverage type should include product line (for example Commercial, Medicare, Medicaid), product (for example PPO, HMO, POS), and benefit (for example drug, mental health).
   3. Rationale: Comprehensive, and hierarchical, coverage type information allows for utility of the data. One individual could fall into several categories within Coverage Type. For example, an individual may be classified as enrolled in an HMO, but under the current element definition, stakeholders would be unable to distinguish if the HMO is a commercial product. In NCQA’s HEDIS reporting structure, we mitigate this challenge by asking organizations to submit multiple records to indicate if a member is in multiple Coverage Type categories. For example, one member enrolled in a commercial HMO with a drug benefit has three sets of records: one indicating commercial enrollment dates, one indicating HMO enrollment dates, one indicating drug benefit enrollment dates. It would be more efficient to have one set of records indicating that the member is in Product line: Commercial; Product: HMO; Benefit: Drug. NCQA created a reference sheet included in Appendix A to inform HL7 community efforts to further refine the Coverage Type structure. We encourage ASTP to consider how to make this data element more granular in USCDI.

Health Status Assessments

1. Smoking Status:
   1. Recommendation type: Modification to existing USCDI element.
   2. Recommendation: Update vocabulary standards to include LOINC in addition to SNOMED CT.
   3. Rationale: Smoking behavior details (i.e., pack-years, quit date, smoking duration) included in the definition of the smoking status element are well defined by LOINC. Comprehensive assessment of smoking behaviors remain a public health priority and is essential to understanding a patient’s eligibility for lung cancer screenings, a screening that is recommended by the U.S. Preventive Services Task Force and that remains underutilized despite its proven effectiveness. NCQA is currently developing measures to incentivize appropriate lung cancer screening for those eligible based on smoking history. We leverage both SNOMED CT and LOINC vocabulary standards to define concepts related to current smoking status and smoking history details to determine screening eligibility.
2. Tobacco Use Status (new element submission)
   1. Recommendation type: Add a new USCDI element.
   2. Recommendation: Add new element for Tobacco Use Status to the Health Status Assessment data class, defined as assessments of a patient’s tobacco use behaviors including use of smoke, vape, chew, or sniff tobacco products. Apply SNOMED CT and LOINC terminology requirements.
   3. Rationale: Tobacco use status encompasses assessment of broader tobacco product use beyond smoked products/cigarettes defined in the existing ‘smoking status’ USCDI element. This broader element aligns with the FDA definition of tobacco products. Comprehensive assessment of tobacco use remains a public health priority and is essential to appropriately providing cessation intervention. Intervention should be provided for any tobacco use, not just cigarettes. NCQA is currently developing a measure to incentivize routine tobacco use screening and cessation intervention.

Orders

1. Referral Orders (new element submission)
   1. Recommendation type: Add a new USCDI element.
   2. Recommendation: Add an additional element to the Orders data class for Referral Orders, defined as a provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. (Vocabulary standards: SNOMED CT)
   3. Rationale: Referral Orders are another important order data element to support care coordination and are already routinely exchanged. Inclusion in USCDI should also facilitate the ability to close the loop on referrals to ensure services requested are carried out, and care is provided, which is the critical step for high-quality, equitable care. NCQA continues to add follow-up components to many new and existing measures to assess for appropriate care following a significant medical finding; referral orders are one component to appropriate follow-up.
2. Medical Device Orders (new element submission)
   1. Recommendation type: Add a new USCDI element.
   2. Recommendation: Add an additional element to the Orders data class for Medical Device Orders, defined as a provider-authored request for medical devices, such as for therapeutic footwear or walking aids. (Vocabulary standards: SNOMED CT)
   3. Rationale: Medical device orders represent another important type of order for appropriate care and patient support. These orders can be captured and exchanged via standard vocabulary. NCQA is currently developing a measure for foot exam and appropriate follow-up in persons with diabetes, as diabetes remains a prevalent and costly disease among adults in the United States.

Explanation of Benefits

1. Carin Blue Button (BB) Common Payer Consumer Data Set (CPCDS) elements:
   1. Recommendation type: Add new USCDI elements.
   2. Recommendation: Add Carin BB CPCDS elements related to explanation of benefits to USCDI v6 to support exchange of adjudicated claims information (without financial information), as proposed by Carin Alliance.
   3. Rationale: The CMS Interoperability and Prior Authorization Final Rule requires payers to share patient claims and encounter data with in-network providers with whom the patient has a treatment relationship. This requirement provides a direct scenario where EHRs may begin to accept, store and use Carin BB CPCDS elements. Adding CPCDS elements under the Explanation of Benefits data class to USCDI aligns requirements across payers and health IT, and will improve data sharing abilities across health plans and providers. Information sharing reduces redundancy in data collection, can improve the patient experience, and can support record location.

Patient Demographic/Information

1. Race and Ethnicity
   1. Recommendation type: Modification to existing USCDI elements
   2. Recommendation: Update the Race and Ethnicity data elements to align with the OMB revisions to the Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (SPD 15), published on March 29, 2024. First, in alignment with the revised SPD 15, we recommend ASTP combine the individual race and ethnicity elements to create one data element: Race and/or Ethnicity. Second, we recommend ASTP update the vocabulary standards for the Race and/or Ethnicity data element to reference the March 2024 revised SPD 15.
   3. Rationale: We appreciate ASTP’s recent HTI-2 proposals regarding race and ethnicity and look forward to ASTP’s promulgation of the standards into the USCDI requirements to support alignment to the revised OMB standards and collection and exchange of more accurate and useful race and/or ethnicity data.

Future Considerations

Provenance

NCQA supports the continued exploration and advancement of provenance data elements, as we understand the critical importance of provenance for data lineage and data validation to support confidence in the data being exchanged. This is particularly important for equity data, where lack of provenance has made data quality checks and prioritization difficult. We applaud the ongoing efforts including TEFCA to address provenance.

Thank you for the opportunity to comment. We remain committed to working with ASTP to build a more equitable, sustainable and responsible American health care system. If you have any questions, please contact Eric Musser, Vice President of Federal Affairs, at (202) 955-3590 or at musser@ncqa.org.

Sincerely,

Margaret E. O’Kane
President