April 30, 2022
Micky Tripathi, PhD, MPP
Office of the National Coordinator for Health Information Technology
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 you for the opportunity to comment on the draft version 3 of the US Core Data for Interoperability (USCDI). We appreciate the ONC’s leadership and strongly support USCDI’s role to identify and implement a foundational set of electronic health information for interoperable health data exchange.
NCQA is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality through our Accreditation, measurement and data quality programs. We are a national leader in quality oversight and a pioneer in digital quality measurement. As market leader in health care quality, we often work with a variety of stakeholders to drive alignment across the health care system. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges of transitioning to the digital future. Our mission to improve the quality of health for all Americans through measurement, transparency and accountability, and our focus on health equity and support for meaningful value-based payment models, propels our daily work.
NCQA is pleased to provide the following comments on the proposals and considerations outlined for USCDI version 3.
- Are there any improvements needed in the data classes or elements included in Draft USCDI v3, including:
a. Appropriate and meaningful data class and element names and definitions?
Health Insurance Information: NCQA is pleased that USCDI v3 includes several priority data classes and elements that are essential to health care quality, including a new data class on health insurance information. But although we are encouraged by this addition, for the Coverage Type data element we recommend ONC adopt a hierarchical structure; for example:
Product Line: Commercial, Medicare, Medicaid, Exchange
Product: HMO, POS, PPO, EPO
Benefit: Drug benefit, Mental health benefit
Because there are not multiple data elements to store this information, one individual could fit into several categories in Coverage Type, making it difficult to discern how industry stakeholders are using that data element. For example, an organization might classify its members as enrolled in an HMO, but under the current proposal, stakeholders would be unable to distinguish if the HMO is a commercial product.
To mitigate this challenge in NCQA’s HEDIS reporting structure, we currently ask organizations to submit multiple records to indicate if a member is in multiple Coverage Type categories. One member enrolled in a commercial HMO with a drug benefit would have three sets of records: one indicating commercial enrollment dates, another 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. We believe this process can be improved greatly by the efforts of USCDI, and we encourage ONC to consider how to make this data element more granular.
Health Status: We believe the Pregnancy Status data element should be expanded to include gestational age (a core concept, and codable) so that if a patient is deemed currently pregnant, the gestational age of their baby can help determine potential risks and exposures critical to different stages of pregnancy.
b. Representative examples or value sets used by health IT developers and implementers to fully understand the intent of the data element?
Health Insurance Information: In our view, both the Source of Payment Typology Payer value set and the HL7 FHIR® Coverage Type and Self-Pay Codes value set are incomplete solutions. For example, millions of Americans are covered by a Marketplace/Exchange plan, but Exchange is not represented in the value sets. We encourage ONC to work with developers to ensure that value sets represent the full picture of coverage types across the nation.
- Should other data elements classified as Level 2 be added to USCDI v3 instead, or in addition to those included in Draft USCDI v3? If so, why?
The inclusion of sexual orientation and gender identity in USCDI v2 was an important step forward for ensuring equitable and appropriate care for sexual and gender minority populations. NCQA encourages ONC to align with recent recommendations from the National Academies (“Measuring Sex, Gender Identity and Sexual Orientation,” March, 2022) and with the minimum value sets put forward in the HL7 Gender Harmony Project ballot.
Sexual Orientation: NCQA recommends disaggregating and expanding the response options to align with those proposed by the Gender Harmony project. We also propose revising the response “Something else, please describe” to “Not listed, please describe.”
Sex (Assigned at Birth) and Gender Identity: NCQA supports retaining the current “two-step” approach, which aligns with recent recommendations from the National Academies. With regard to existing code lists, NCQA recommends expanding the NullFlavor options to include ASKU, “Asked but No Answer” (e.g., patient prefers not to answer or declines to answer).
Additional Concepts: NCQA supports the addition of the Personal Pronouns concept (as proposed by Gender Harmony and represented in LOINC through “Observation: 90778-2 Personal Pronouns – Reported” and “Answer list: LL5144-2 Personal pronouns 126.96.36.199.4.1.12009.10.1.4011.”)
Last, we want to express our appreciation for ONC’s USCDI+ initiative to define additional standardized interoperable data elements needed for quality measurement. NCQA is committed to transforming our quality measures to digital, and USCDI and USCDI+, will allow us to build on a foundational framework for this transition. We encourage ONC to leverage the expertise of measure stewards (like NCQA) to identify data elements that can enable a future, of near real-time, digital quality measurement.
Thank you again for the opportunity to comment. We remain committed to improving the nation’s health care system and we welcome a discussion on our recommendations. If you have any questions, please contact Eric Musser, NCQA Director of Federal Affairs, at (202) 955-3590 or at firstname.lastname@example.org.
Margaret E. O’Kane