US Core Implementation Guide
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US Core Implementation Guide, published by HL7 International - Cross-Group Projects. This is not an authorized publication; it is the continuous build for version 6.0.0-preview). This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Screening and Assessments

This page is new content for US Core Version 6.0.0

This page documents how US Core Profiles can represent screenings and assessments. The Gravity Project) published the SDOH Clinical Care HL7 Implementation Guide, which documents the orchestration of SDOH data capture and related interventions and how to represent it using FHIR. These efforts led to many additions to US Core 5.0.1 updates to meet the USCDI v2 Social Determinant of Health (SDOH) data elements: SDOH Assessments, SDOH Goals, SDOH Interventions, and SDOH Problems/Health Concerns. Since screenings and assessments are not unique to social needs, US Core 6.0.0+ Profiles and the FHIR RESTful interactions documented below span across use cases and thus are less constrained and form the backbone for the Clinical Care Profiles. They provide a general framework for all domains which use screenings are assessments, including the USCDI v2 and USCDI v3 data classes:

  • SDOH
  • Functional Status
  • Disability Status
  • Mental/Cognitive Status.

The figure below shows how screenings, assessments, and referrals (requests) relate to providing the services required by a patient.

  • Screening and Assessments: An accurate Screening and Assessment is necessary before delivering appropriate clinical care. US Core defines two observations to support this process:
    • US Core Observation Screening Assessment Profile - represents the questions and responses to screening and assessment tools. It can represent a single response, multiple responses, and multi-select “check all that apply” type questions.
    • US Core Simple Observation Profile - a clinician’s decision to document a specific item - “patient has problems with housing”. Note this observation is only appropriate when the judgment isn’t appropriate on the list of Problems or Health Concerns.
  • Problems/Health Concerns: Identifying a Health-related condition (for example, homelessness), Disability concern, or Functional concern is represented by the US Core Condition Problems and Health Concerns Profile.
  • Interventions: The US Core ServiceRequest Profile communicates services offered to patients to address problems/health concerns. The US Core Procedure Profile can also record a completed service or intervention.
  • Goals: Identifying and defining a future desired condition or change in condition (for example, Has adequate quality meals and snacks) is represented by US Core Goal Profile.
Screening and Assessment Activities
screening_and_assessments.svg

Screening and Assessments

Screening and Assessments are used to identify various problems or health concerns. Their complexity ranges from simple observations to complex structured evaluations:

  • Clinician makes a ‘clinical judgment’ - I found patient has this problem
  • Clinician completes and shares detailed assessments
  • Clinician makes a ‘clinical judgment’ based on detailed assessment.

The following guidance was developed after reviewing several functional status, disability status, mental/cognitive status, and SDOH screening and assessment tools.

US Core Observation Screening an Assessments Profile

To meet the requirements for USCDI v3 data class Health Status and Assessments and SDOH Assessments, US Core defines the US Core Observation Screening Assessment Profile to support questions and responses to screening and assessment tools when an assessment is done. It can represent a single response, multiple responses, and multi-select “check all that apply” type questions. It also records a total score when a screening or assessment tool includes one. US Core Servers SHALL support the US Core Observation Screening Assessment Profile for recording screening and assessments.

The US Core Observation Screening Assessment Profile is defined to record responses from screening or assessments for any context. In addition, the profile defines references to other screening and assessment observations. A web of related observations is grouped using these references, and the structure is preserved. The figure below illustrates the relationship between the Observation screening and assessments “panel” and the individual screening and assessment Observations. Each box represents an Observation:

Relationship Between Screening and Assessment Observations
uscore-observation-assessment-structure.svg

Note that the panels can be nested to create additional groupings of responses. See the US Core Observation Screening Assessment Profile profile page for detailed documentation on how the observations are linked, examples, and search requirements.

Not all questions and answers in an assessment tool may or should be represented as FHIR Observations. For example, the FHIR patient resource best represents patient demographic information.

US Core Observation Simple Observation Profile

Systems record clinical judgments as a problem or health concerns or as observations. For systems that support clinical judgments as observations, US Core defines a US Core Simple Observation Profile to represent these findings (for example, “I found patient X has this problem”). US Core Servers MAY support this profile. This observation can contribute to the identification of future problems or health concerns and support service requests and procedures. When a Simple Observation or Problem or Health Concern is recorded based on an Assessment or Screening tool, systems SHOULD associate it with the US Core Observation Screening and Assessments observation.

What About QuestionnaireResponse?

In US Core 5.0.1, systems could optionally support the US Core QuestionnaireResponse Profile for SDOH Assessments. In US Core 6.0.0+, the US Core QuestionnaireResponse Profile has been removed.

The rationale for this decision is summarized below:

  • Promoting two different ways to exchange the same data forces Clients to support both structures and complicates future FHIR Write efforts.
  • Transforming QuestionnaireResponse to Observations is necessary if a system only supports Observations.
  • Clients can not query individual responses in QuestionnaireResponse.
  • Potential clinical safety issues with information spread across two resources.

Searching for Screening and Assessment Data

Below is a simple example of a FHIR RESTful search transaction on Observation to access a patient’s SDOH assessment data

  • Patient’s FHIR_id = “example”
  • Observation category = “sdoh”

Request

Request url using GET

GET http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient/example&category=sdoh

Request Headers

User-Agent: python-requests/2.25.1
Accept-Encoding: gzip, deflate
Accept: application/fhir+json
Connection: keep-alive
Content-Type: application/fhir+json

Response

200 OK

Response Headers

Connection: keep-alive
Content-Location: http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=sdoh
Content-Type: application/fhir+json;charset=utf-8
Content-Length: 4112
Date: Sun, 21 Nov 2021 03:15:18 GMT

Response Body

{
  "resourceType": "Bundle",
  "id": "158f4b97-5b3a-4363-81da-19d454a6df30",
  "meta": {
    "versionId": "1",
    "lastUpdated": "2021-11-20T22:15:18.726-05:00"
  },
  "type": "searchset",
  "total": 1,
  "link": [
    {
      "relation": "self",
      "url": "http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=sdoh"
    }
  ],
  "entry": [
    {
      "fullUrl": "http://wildfhir4.aegis.net/fhir4-0-1/Observation/hunger-question-example",
      "resource": {
        "resourceType": "Observation",
        "id": "hunger-question-example",
        "meta": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-name",
              "valueString": "Hunger Question Example"
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-description",
              "valueMarkdown": "This is a Hunger Question Example for the *US Core Screening Response Observation Profile*."
            }
          ],
          "versionId": "1",
          "lastUpdated": "2021-11-20T22:13:54.070-05:00",
          "profile": [
            "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response"
          ]
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>meta</b>:       \n      </p><p><b>status</b>: FINAL      \n      </p><p><b>category</b>: SDOH         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'sdoh' = 'sdoh', given as 'SDOH'})</span>, Survey         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'survey' = 'Survey', given as 'Survey'})</span></p><p><b>code</b>: Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '88122-7' = 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]', given as 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]'})</span></p><p><b>subject</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>effective</b>: Nov 12, 2021 8:59:15 PM      \n      </p><p><b>performer</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>value</b>: Often true         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'LA28397-0' = 'Often true', given as 'Often true'})</span></p><p><b>derivedFrom</b>: Hunger Vital Signs Questionnaire      \n      </p></div>"
        },
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://loinc.org",
                "code": "sdoh",
                "display": "SDOH"
              }
            ]
          },
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                "code": "survey",
                "display": "Survey"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "88122-7",
              "display": "Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]"
            }
          ]
        },
        "subject": {
          "reference": "Patient/example"
        },
        "effectiveDateTime": "2021-11-12T17:59:15-08:00",
        "performer": [
          {
            "reference": "Patient/example"
          }
        ],
        "valueCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "LA28397-0",
              "display": "Often true"
            }
          ]
        },
        "derivedFrom": [
          {
            "display": "Hunger Vital Signs Questionnaire"
          }
        ]
      },
      "search": {
        "mode": "match",
        "score": 1
      }
    }
  ]
}


Terminology

Category Codes

The [US Core Assessment Category Value Set] categorizes contexts for Assessments, Problems, and Service Requests. These concepts enable API consumers to select contexts (for example, SDOH) when accessing patient information. Example searches are shown in each profile’s Quick Start sections.

Clients need to understand that data categorization is somewhat subjective. The categorization applied by the source may not align with the client’s expectations. Clients may find it more beneficial to use queries based on a specific code or set of codes or to perform additional client-side filtering of query results.

Codes for Problems/HealthConcerns, Goals, Service Requests, and Procedures

For the SDOH Clinical Care HL7 Implementation Guide, the Gravity project has defined the following value sets across specific social risk factor domains for problems/health concerns, goals, procedures, and service requests:

US Core uses broadly defined value sets that contain concepts used across many use cases, including SDOH. The figure below illustrates how the Gravity value sets are grouped for use in the US Core Condition Problems and Health Concerns Profile and how the grouped valueset is compatible with the US Core Problem code valueset. When recording SDOH data US Core Profiles, servers SHOULD use the SDOH value sets listed above.

Example of SDOH Grouping Value set in US Core Condition Codes Value Set
sdoh_condition.svg