PACIO Transitions of Care Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-transitions-of-care-ig/ and changes regularly. See the Directory of published versions

Selecting Discipline-Specific Data Elements from the CMS Data Element Library

Page standards status: Informative

The Centers for Medicare & Medicaid Services (CMS) Data Element Library (DEL) is a centralized repository that provides standardized definitions and mappings for data elements used in post-acute care (PAC) assessments, such as the Minimum Data Set (MDS), the Outcome and Assessment Information Set (OASIS), and the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI). By offering consistent terminology and interoperability standards, the DEL can significantly inform and improve transitions of care, particularly for patients moving between care settings. Below is an explanation of how the DEL contributes to transitions of care, supported by references:

Standardized Data for Continuity of Care

The DEL ensures that PAC providers use standardized data elements, which are mapped to health IT standards such as Logical Observation Identifiers Names and Codes (LOINC) and Systematized Medical Nomenclature for Medicine–Clinical Terminology (SNOMED CT). This standardization allows for seamless communication and data exchange between different care settings, reducing the risk of errors or omissions during transitions of care.

Supporting Reference: CMS emphasizes that the DEL supports interoperability by aligning data elements with standards required for electronic health records (EHRs) under the 21st Century Cures Act. This alignment ensures that data can be shared across systems without loss of meaning or accuracy. (Centers for Medicare & Medicaid Services, 2023)

Improved Care Coordination

The DEL facilitates the sharing of critical patient information, such as functional status, cognitive abilities, and social determinants of health, which are essential for care planning during transitions. For example, when a patient is discharged from a skilled nursing facility to home health care, the receiving provider can access standardized data to tailor interventions to the patient’s needs.

Supporting Reference: Research shows that standardized data improves care coordination by enabling providers to quickly understand a patient’s clinical status and history, reducing the likelihood of adverse events during transitions. (Kripalani et al., 2007, JAMA)

Compliance with Interoperability Mandates

The DEL supports compliance with federal interoperability mandates, such as the CMS Interoperability and Patient Access Final Rule. By using DEL data elements, providers can ensure that patient information is shared in a format that meets regulatory requirements, promoting smoother transitions of care.

Supporting Reference: CMS states that the DEL is a key resource for aligning PAC data with interoperability requirements, ensuring that providers can meet regulatory standards while improving patient outcomes. (CMS, 2023)

Facilitating Patient-Centered Care

The DEL includes data elements that capture patient preferences, goals, and outcomes, which are critical for delivering patient-centered care during transitions. For example, understanding a patient’s mobility goals or pain management preferences can help ensure that care plans are aligned with their needs as they move between settings.

Supporting Reference: Studies highlight the importance of incorporating patient preferences into care transitions to improve satisfaction and outcomes. Standardized data elements, like those in the DEL, make this integration feasible. (Coleman, 2003, Annals of Internal Medicine)

Reducing Readmissions and Adverse Events

By providing accurate and comprehensive data during transitions, the DEL helps reduce hospital readmissions and adverse events. Standardized data ensures that critical information, such as medication reconciliation and discharge instructions, is consistently communicated to the next care provider.

Supporting Reference: Evidence suggests that poor communication during transitions is a leading cause of readmissions and adverse events. The use of standardized data, like that in the DEL, mitigates these risks. (Jencks et al., 2009, New England Journal of Medicine)

In Summary

The CMS Data Element Library is a powerful tool for improving transitions of care by promoting standardized, interoperable, and patient-centered data exchange. Its alignment with health IT standards and regulatory requirements ensures that providers can deliver high-quality care while reducing risks associated with care transitions.

The PACIO Community divided into several sub-groups, each representing a different medical discipline, to produce a minimum set of data elements that can support each discipline and provide comprehensive transitions of care information to a new facility receiving a patient. The different groups included:

• Dieticians
• Doctors, Nurse Practitioners (NPs), Physician Assistants (PAs)
• Occupational and Physical Therapists (OT/PTs)
• Speech and Language Pathologists
• Pharmacists
• Nurses
• Behavioral Health Specialists

Data elements from additional disciplines will be added as time and availability permits. If you are interested in participating in this analysis, please contact us at info (at) pacioproject.org.

Transitions of Care Data Elements

The result of that analysis has been captured in the DEL Role-based Analysis Spreadsheet:

References

• Centers for Medicare & Medicaid Services (CMS). (2023). Data Element Library Overview. Retrieved from https://www.cms.gov
• Kripalani, S., et al. (2007). "Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians." JAMA, 297(8), 831-841.
• Coleman, E. A. (2003). "Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care." Annals of Internal Medicine, 141(7), 533-536.
• Jencks, S. F., et al. (2009). "Rehospitalizations Among Patients in Medicare Fee-for-Service Program." New England Journal of Medicine, 360(14), 1418-1428.