NCQA Comments on ONC’s USCDI Draft v4

NCQA is pleased to provide comments on the proposals and considerations outlined for USCDI version 4.

April 27, 2023

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 provide feedback on draft version 4 of the US Core Data for Interoperability (USCDI).

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 comments on the proposals and considerations outlined for USCDI version 4.

  1. Are there any improvements needed in the data classes or elements included in Draft USCDI v4, including:

    a. Appropriate and meaningful data class and element names and definitions?

    Encounter Identifier: NCQA is pleased that Encounter Identifier is included as a data element in USCDI v4, and we believe it will enhance quality measurement.

    This identifier will allow tracking of a specific medical event and the observations, procedures, services and other data linked to that event across the care continuum. With the expansion of digital health and home-based hospital services, there is an increasing need to monitor the value and quality of these programs as alternatives to traditional health care settings. A standardized encounter identifier will encourage this. NCQA welcomes the opportunity to partner with ONC in developing guidelines that support standardization.

    Alcohol Use/Substance Use: We support including Alcohol Use/Substance Use data elements in USCDI v4. This addition will support CMS’s efforts to advance quality measurement for behavioral health and pain management, as outlined in the agency’s Behavioral Health Strategy, and will allow NCQA and other measure stewards to produce next-generation digital behavioral health measures. Further, we encourage ONC to explore including instrument type or name and collection method as components of these data elements. Quality measures allow use of a variety of clinically valid instruments and administration methods, but not all. We encourage aligning with existing PCORnet standards for this data element.

    Average Blood Pressure: We are pleased that Average Blood Pressure is included in USCDI v4. Quality measures using blood pressure are considered a high-priority measurement area in many quality and accountability programs, and average blood pressure is important for diagnosing and treating hypertension. We encourage ONC to clarify a standard for calculation. A taskforce led by the American College of Cardiologists and American Heart Association provides guidance for calculating clinician- and self-measured average blood pressure. An average of readings on separate occasions minimizes random error and provides a more accurate basis for estimating blood pressure than individual readings. Average blood pressure is not equivalent to, nor a replacement for, mean arterial pressure. Both are needed to guide clinical care and quality measurement.

    Health Insurance Information: NCQA is pleased that USCDI v3 includes 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 again recommend that 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 in which to store this information, one individual could fall into several categories in Coverage Type, making it difficult to discern how industry stakeholders use the data element. For example, an organization might classify members as enrolled in an HMO, but under the current proposal, 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. We believe this process can be improved by the efforts of USCDI, and we encourage ONC to consider how to make this data element more granular.

    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.

  2. Should other data elements classified as Level 2 be added to USCDI v4 instead, or in addition to those included in Draft USCDI v4? If so, why?

    Including sexual orientation and gender identity in USCDI v2 was an important step toward 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 and Gender Identity: NCQA supports retaining the current “two-step” approach, which aligns with recent recommendations from the National Academies. Further, NCQA encourages USCDI to consider expanding sex-related data elements to include the Gender Harmony Project data element Sex for Clinical Use. Including this data element will begin to enable documentation and exchange of structured data based on clinical observation, and reflects a step toward anatomy-based identification of clinical need.

    Smoking Status: NCQA encourages expanding the Smoking Status data elements in the USCDI v4 to include, at a minimum, cigarette pack years and quit date. These components are currently listed as comment level, but are pivotal to clinicians in understanding patient risk and identifying the need for lung cancer screening. Including them will enhance structured documentation and exchange of crucial smoking history data, and will accelerate implementation of quality measures to improve rates of lung cancer screening, increasing early detection and reducing lung cancer mortality.

    Additional Concepts: NCQA supports adding 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”).

    We strongly urge including the FHIR QuestionnaireResponse in future versions of the USCDI to improve the exchange of social needs data. This recommendation was made in a Joint Statement with NCQA, the Joint Commission and the National Quality Forum. This will support PROMs and other patient assessments used in quality improvement programs.

We look forward to supporting our federal partners in advancing the Quality Domain for USCDI+. Transforming our quality measures to digital and USCDI will allow us to build on the framework of data standardization. We continue to encourage ONC to leverage the expertise of measure stewards (such as NCQA) to identify data elements that can enable a future of near real-time 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, Assistant Vice President of Federal Affairs, at (202) 955-3590 or at

Eric Musser
Assistant Vice President, Federal Affairs

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