6.0 Document Updates

[1] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[2] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[3] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[4] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[5] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[6] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[7] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[8] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[9] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[10] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[11] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[12] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[13] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[14] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[15] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[16] Optionality = R for Required, R2 for Required if known, O for Optional, or C for Conditional. If applicable, conditional footnotes are further described below.

[17] SNOMED CT has integratedseveral of the ANA recognized nursing terminologies (Omaha System, CCC, NIC, NANDA, NOC, PNDS). LOINC, ICNP (International Classification of Nursing Practice), ABC Codes and NMMDS (Nursing Management Minimum Data Set) have not yet been fully mapped to SNOMED. These additional mappings must occur. As content evolves within specific standard nursingterminologies, as long as nursing terminologies maintain the mapping relationships with SNOMED CT, they will be fully compatible with interoperability. For purposes of interoperability with respect to the ONC Quality Use Case, mapping is required through SNOMED CT. While there is established value for individual interface nursing terminologies (e.g., CCC and Omaha System, both in the public domain), for collection of data, interoperability within the scope of the Use Case is best managed with SNOMED CT. The need to enhance visibility of nursing and other disciplines can best be managed through specific use cases developed in the future for that purpose. Therefore, SNOMED CT is the identified terminology for use in the Quality Use Case.

[18] We recognize the existence of CPT II as a new administrative coding system to collect measurement required data elements. The long-term goal for interoperability is to use clinical terminology allowing the repurposing of data created as part of routine clinical care delivery. For the short term, CPT II codes may be useful to capture required data for measurement calculation, especially with respect to exclusion criteria inherent in many measures. The Technical Committee has recommended standards and terminologies to enable clinical data element standardization which will require work effort by EHRs, receiving systems and clinical measurement and guideline developers. Such standardization will support repurposing of routine clinical care data for quality measurement without interposition of additional coding schema such as CPT II.

[19] http://www.qualityforum.org/projects/ongoing/HITEP/txHITEP_finaldraft.pdf

[20] http://www.qualityforum.org/projects/ongoing/HITEP2/HITEP2_Report_Draft_06092009.pdf

[21] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[22] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[23] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No

[24] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[25] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[26] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[27] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[28] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[29] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No

[30] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[31] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No

[32] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[33] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[34] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[35] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[36] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[37] Not limited to that known at the end of encounter

[38] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[39] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions

[40] Not limited to that known at the end of encounter

[41] Optionality = R for Required, R2 for Required if Known or O for Optional, or C for Conditional. Repeatable = Y for yes, N for No.

[42] May have constraints that identify Limit/Range of values, Data Source, and/or Requirements/Pre-conditions