HL 7 FHIR Connectathon Gravity SDOHCC Track Overview

HL 7 FHIR Connectathon Gravity SDOH-CC Track Overview of SDOHCC Profiles Monique van Berkum January 14, 2020 © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office.

Agenda – Overview of SDOHCC Approach • • References between SDOHCC Profiles SDC Questionnaire Instance SDC Questionnaire. Response Example SDOHCC Profiles and Examples – SDOHCC Observation Screening. Response. Base 1 – SDOHCC Condition Base 1 – SDOHCC Service. Request Base 1 – SDOHCC Procedure Base 1 – SDOHCC Task Base 1 – SDOHCC Goal Base 1 • Questions Disclaimer 2

SDOH Profiles – Sequence of Progression • Questionnaire. Response(s) • Screening Response Observation(s) - autogenerated • Condition(s) (Health Concern) - autogenerated • Goal(s) (and later, possibly Care Plan) • Service Request(s) and Task • Procedure(s)/Intervention(s) • Subsequent Observation(s) and Condition(s) • Revised Goal(s) (and Care. Plan) © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 3

SDOH CC Resource References 4

Questionnaire – LOINC® 88121 -9 Hunger Vital Sign [HVS] • Questionnaires used for SDOH-CC must be LOINC encoded. • SDC Questionnaire instance is created using LHC Form Builder. • SDOHCC Questionnaire Hunger. Vital. Sign 1 instance: © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 5

SDC Questionnaire. Response (FHIR SDC SMART App) SDOHCC Questionnaire. Response Hunger. Vital. Sign Example 1 • Questionnaire. Response is created using the FHIR SDC SMART App • Questionnaire. Response contains all QA pairs from a Questionnaire • Each QA pair will become an Observation represented by an SDOHCC Observation profile • Screening. Response Observations will be autogenerated from Questionnaire. Response

SDOHCC Observation Screening. Response. Base 1 7

SDOHCC Observation Screening. Response. Base 1 (cont. ) • Observation. category – Requires Social History and Survey codes from HL 7 “Observation Category Codes” value set’. – Allows a code from SDOHCC-Value. Set-SDOHDomain-1 to specify an SDOH Domain (e. g. , Food Insecurity). • Observation. code and Observation. value – Currently, bound to FHIR "LOINC Codes" value set. – Overtime, value sets will be refined to LOINC codes that pertain to SDOH domains. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 8

SDOHCC Observation Screening. Response. Base 1 (cont. ) • Observation. data. Absent. Reason – Bound to FHIR “Data. Absent. Reason” value set • Observation. data. Absent. Reason and Observation. value – There may be semantic overlap in information represented by these element. – LOINC Normative Answer Lists used for Observation. value may include codes that overlap with values in the “Data. Absent. Reason” value set. – If a LOINC Normative Answer List offers an adequate code for why an Observation. value may not be known, it should be used as the value for Observation. value. – If the LOINC Normative Answer List for a LOINC code does not offer an adequate code for why an Observation. value may not be known, Observation. data. Absent. Reason should be used in lieu of Observation. value. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 9

Observation. value vs. Observation. data. Absent. Reason • LOINC 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] • LOINC 88123 -5 Within the past 12 months the food we bought just didn't last and we didn't have money to get more [U. S. FSS] • For 88122 -7 and 88123 -5, the Answer List (LL 4730 -9) includes LA 15775 -2 Don't know/refused. • LA 15775 -2 overlaps with “asked-declined” in the Data. Absent. Reason value set. • In this case, use Observation. value: LA 15775 -2 in lieu of Observation. data. Absent. Reason. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 10

Observation. value vs. Observation. data. Absent. Reason • LOINC 88124 -3 Food insecurity risk [HVS] is calculated based on the patient’s answers for the first two questions 88122 -7 and 88123 -5. • Food insecurity risk [HVS] cannot be calculated if the patient’s answers for 88122 -7 and 88123 -5 are LA 15775 -2 Don't know/refused. • The LOINC Answer list for 88124 -3 Food insecurity risk [HVS] does not offer an “Unknown” option. • Therefore Observation. value cannot be used to express “Unknown”. • In this case, use Observation. data. Absent. Reason: Unknown. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 11

SDOHCC Observation Screening. Response. Base 1 (cont. ) • Observation. subject – US Core profiles use US Core Patient for Observation. subject. • US Core does not offer a generic Observation Profile. Therefore, Observation. subject references Patient. • However, Observation. subject will generally use US Core Patient. - If an implementer is creating US Core profiles (e. g. , US Core Condition, US Core Procedure, etc. ) that require US Core Patient for Subject, then US Core Patient should also be used for Subject in other SDOHCC profiles (e. g. , Observation, Service. Request, etc. ) which do not currently specify US Core Patient. • Observation. performer – For Observations generated from a single QA pair answered directly by the Observation. subject, Observation. performer is generally the same as Observation. subject. – For Observations derived from other Observations, leave performer empty. • In that case, Observation. derived. From may reference multiple Screening. Response Observation(s). • See SDOHCC Observation Hunger. Vital. Sign Example 3. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 12

SDOHCC Observation Screening. Response. Base 1 (cont. ) • Observation. derived. From – May reference the Questionnaire. Response that contains the Question/Answer pair (QA pair) represented by the Observation. – May reference multiple Screening. Response Observations. • For Observations that are “computed/derived” based on other Observations as opposed to generated from a single QA pair answered directly by the subject. • See SDOHCC Observation Hunger. Vital. Sign Example 3. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 13

Observation Examples for LOINC Hunger Vital Sign [HVS] • LOINC Hunger Vital Sign™ 88121 -9 – Questions 88122 -7 and 88123 -5 are answered directly by the patient. – An answer of "often true" or "sometimes true" to either 88122 -7 or 88123 -5 identifies a patient as "At risk" for food insecurity. – Food insecurity risk [HVS] 88124 -3 is not directly answered by the patient. – Food insecurity risk [HVS] 88124 -3 is derived from answers to 88122 -7 and 88123 -5. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 14

SDOHCC Observation Screening. Response. Base 1 SDOHCC Observation Hunger. Vital. Sign Example 1 • This Observation represents a single QA pair (88122 -7) answered directly by the patient. • It has a performer and derived. From references only Questionnaire. Response (QR-5770275). Note: In the 0. 1. 0 - STU 1 IG, this example is missing Performer and the derived. From reference to Questionnaire. Response (QR-5770275). This will be corrected in the next version. 15

SDOHCC Observation Screening. Response. Base 1 SDOHCC Observation Hunger. Vital. Sign Example 3 • Food insecurity risk [HVS] 88124 -3 Observation is not answered directly by the patient. It is derived from the other two HVS Observations. • This Observation does not have a performer and, in addition to referencing Questionnaire. Response (QR-5770275), derived. From also references the other two HVS Observations (88122 -7 and 88123 -5). Note: In the 0. 1. 0 - STU 1 IG, this example is missing the derived. From reference to Questionnaire. Response (QR-5770275). This will be corrected in the next version. 16

SDOHCC Observation Screening. Response. Base 1 SDOHCC Observation Hunger. Vital. Sign. Group Example 1 • Example of an Observation group that uses Observation. has. Member to reference the Observations that represent the individual Question and Answer pairs (QA pairs) from the Questionnaire. • References the 3 Observations for the 3 questions from 88121 -9 Hunger Vital Sign [HVS]. Note: In the 0. 1. 0 - STU 1 IG, this example is missing some O bservation elements (e. g. , Observation. subject). This will be corrected in the next version. 17

SDOHCC Condition Base 1 18

SDOHCC Condition Base 1 • Based on US Core Condition Profile • SDOHCC Condition/Health Concern – May be autogenerated from Questionnaire. Responses and/or their corresponding Screening. Response Observations. • Condition. category – Requires a code from “US Core Condition Category Codes” value set. • Value set contains: Problem List Item, Encounter Diagnosis and Health Concern • For Conditions autogenerated from QA pairs on an SDOH Questionnaire, use Condition. category: Health Concern. – Allows a code from SDOHCC-Value. Set-SDOHDomain-1 to specify an SDOH Domain (e. g. , Food Insecurity). © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 19

SDOHCC Condition Base 1 • Condition. code – Currently, bound to "US Core Condition Code" value set. – Condition. code. coding is sliced to allow optional addition of ICD-10 codes to document SDOH conditions for the purpose of billing. • Currently, the ICD-10 Coding slice binds to the FHIR “ICD-10 Codes” value set. – Overtime, the value sets will be refined to codes that pertain to SDOH domains. • Condition. subject – References US Core Patient. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 20

SDOHCC Condition Base 1 (cont. ) • Condition. severity – Severity will likely apply only to a limited subset of SDOH condition codes. • Severity could be used for the SDOH domain of “Food insecurity”. – Subtypes include “Mild food insecurity”, “Moderate food insecurity” and “Severe food insecurity”. – “Mild”, “moderate” and “severe” fit nicely into severity rankings/value sets. • For SDOH domains, like “Homelessness”, severity might be expressed differently. – Subtypes include “Sheltered homelessness” and “Unsheltered homelessness”. – “Sheltered” and “unsheltered” do not fit into the traditional set of severity rankings. – Rather, “Sheltered homelessness” and “Unsheltered homelessness” will be represented using precoordinated terminology codes bound to Condition. code. – Condition. severity might be useful for a small subset of SDOH conditions but is currently prohibited to facilitate a consistent approach where the full meaning of a condition is represented by Condition. code. – This should facilitate querying, analytics, and mapping to ICD. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 21

SDOHCC Condition Base 1 (cont. ) • Condition. asserter – For Conditions that are autogenerated based on the patient directly answering an individual QA pair from an SDOH screening questionnaire: • Condition. asserter should be the patient. • Condition. evidence. detail should reference the Screening. Response Observation that was used to autogenerate the Condition. – For Conditions that are “computed/derived” based on the patient‘s answers to multiple QA pairs: • Condition. asserter should be left empty. • Condition. evidence. detail may reference one or more Screening. Response Observations that were used to compute the Condition. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 22

SDOHCC Condition Base 1 (cont. ) • Condition. evidence – Condition. evidence. detail • Provides supporting evidence that is the basis for a Condition and its verification. Status. • Conditions generated from Questionnaires will likely reference SDOHCC_Observation_Screening. Response. Base_1 instance(s). – Condition. evidence. code • Provides supporting manifestations/symptoms that are the basis for a Condition and its verification. Status. • Currently, binds to the FHIR “Manifestation and Symptom Codes” value set. • Overtime, the value set may be refined to codes that pertain to SDOH domains. – Condition. evidence. code and Condition. evidence. detail may represent similar information. Where there is significant overlap, use Condition. evidence. detail. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 23

SDOHCC Condition Base 1 SDOHCC Condition Hunger. Vital. Sign Example 1 • Condition. code is 733423003 |Food insecurity (finding)| because Observation that is evidence for this condition is “Food insecurity risk” which fits into the spectrum of the Gravity definition of “Food insecurity”. • Condition. evidence. detail references the Food insecurity risk [HVS] 88124 -3 Observation which is derived from the other two HVS Observations and there is no Condition. asserter. This condition was not directly asserted. In this case, it was autogenerated. • A clinician interaction may result in a different or additional Condition. code (e. g. , to “Mild food insecurity”). In that case, the clinician would be the asserter and additional Condition. evidence might be added. 24

SDOHCC Service. Request Base 1 25

SDOHCC Service. Request Base 1 • Service. Request. category – Allows a code from SDOHCC-Value. Set-SDOHDomain-1 to specify an SDOH Domain (e. g. , Food Insecurity). • Service. Request. code – Currently, binds to the FHIR “Procedure Codes (SNOMED CT)” value set (binding strength = Example) – Overtime, the value set may be refined to codes that pertain to SDOH domains. • Service. Request. subject – Service. Request. subject references Patient, Group or Location. – FHIR Procedure Resource allows only Patient and Group for Procedure. subject. – US Core Procedure allows only US Core Patient for Procedure. subject. – Since Procedures are often based on Service Requests, changes to the FHIR Procedure Resource and US Core Procedure Profile may be indicated to allow the same references for Procedure. subject as for Service. Request. subject. For example, a “Mold remediation” procedure is performed on a location not a patient. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 26

SDOHCC Service. Request Base 1 • Service. Request. reason. Code – Provides a coded reason for why a service is being requested. – Currently, binds to the FHIR "Procedure Reason Codes" value set (binding strength = Example) – Overtime, the value set may be refined to codes that pertain to SDOH domains. • Service. Request. reason. Reference – Justifies why the procedure was performed. – References SDOHCC_Condition_Base_1 and SDOHCC_Observation_Screening. Response. Base_1, and may also reference Condition, Observation, Procedure, Document. Reference and/or Diagnostic. Report. • Service. Request. reason. Code and Service. Request. reason. Reference may represent similar information. Where there is significant overlap, use Service. Request. reason. Reference. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 27

SDOHCC Service. Request Base 1 SDOHCC Service. Request Hunger. Vital. Sign Example 1 • Service. Request. reason. Reference references the Food insecurity Condition (Health Concern) which was derived from HVS Observations © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 28

SDOHCC Procedure Base 1 29

SDOHCC Procedure Base 1 • Procedure. category – Allows a code from SDOHCC-Value. Set-SDOHDomain-1 to specify an SDOH Domain (e. g. , Food Insecurity). • Procedure. code – Currently, requires the FHIR “Procedure Codes (SNOMED CT)” value set. – Allows optional addition of CPT and HCPCSII codes to document SDOH conditions for the purpose of billing as well as LOINC codes (which may be added to LOINC at a future time to allow further specificity for procedures). – Currently, the bindings are to the full code set for each code system. – Overtime, the value sets may be refined to codes that pertain to SDOH domains. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 30

SDOHCC Procedure Base 1 • Procedure. reason. Code – Can be used to provide a coded reason for why a procedure was performed. – Currently, binds to the FHIR "Procedure Reason Codes" value set. – Overtime, the value may be refined to codes that pertain to SDOH domains. • Procedure. reason. Reference – Can be used to justify why the procedure was performed. – References SDOHCC_Condition_Base_1, SDOHCC_Observation_Screening. Response. Base_1 – May also reference Condition, Observation, Procedure, Document. Reference and/or Diagnostic. Report. • Where there is significant overlap between Procedure. reason. Code and Procedure. reason. Reference, it is recommended to use Procedure. reason. Reference. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 31

SDOHCC Goal Base 1 32

SDOHCC Goal Base 1 • Goal. subject – References US Core Patient • Goal. description – Currently, bound to FHIR "LOINC Codes" value set (Binding strength = Extensible). – Overtime, value sets will be refined to LOINC codes that pertain to SDOH domains. • Goal. target. measure – Currently, bound to FHIR "LOINC Codes" value set (Binding strength = Extensible). – Overtime, the value may be refined to codes that pertain to SDOH domains. • Goal. addresses – References SDOHCC_Condition_Base_1, and SDOHCC_Observation_Screening. Response. Base_1. – May also reference Condition, Observation, and/or Risk. Assesssment. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 33

SDOHCC Goal Base 1 (cont. ) • Goal. expressed. By – Currently FHIR Resource limits this to cardinality of 1. – A joint goal (agreed to by provider and patient) might require separate Goal instances. • Goal. outcome. Code – Can be used identify the outcome when Goal. status is assessed. – Currently, bound to FHIR "LOINC Codes" value set (Binding strength = Example). – Overtime, value sets will be refined to LOINC codes that pertain to SDOH domains. • Goal. outcome. Reference – Can be used to provide details of the Goal outcome (presumably when Goal. status is assessed). – References SDOHCC_Observation_Screening. Response. Base_1 and may also reference Observation. • Where there is significant overlap in information provided by Goal. outcome. Code and Goal. outcome. Reference, it is recommended to use Goal. outcome. Reference. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 34

SDOHCC Task Base 1 35

SDOHCC Task 1 • Task. intent – Bound to Fixed value: order • Task. code – Currently, bound to FHIR “Task Codes" value set (Binding strength = Example). • Task. focus – References SDOHCC_Service. Request_Base_1. • Task. for – References Patient, Related Person, or Group • Task. output – Requires Task. out. type: Resulting Activity © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 36

Questions? © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 37