Comment

Submitted by Lucy Johns on

Gravity Project Recommendations for USCDI v.2 Level 2

Health Care Planning and Policy
1736 Stockton Street – Suite #9 San Francisco CA 94133 ljohns@metacosmos.org

LUCY JOHNS MPH (415) 896 4455

By electronic submission

The Honorable Donald Rucker, M.D.
National Coordinator for Health Information Technology U.S. Department of Health and Human Services
330 C Street SW, 7th Floor
Washington, D.C. 20201

December 8, 2020

Re: The Gravity Project’s Submission To Include Social Determinants of Health in the U.S. Core Data for Interoperability, Version 2, for Better Care and Better Health Nationwide

Dear Dr. Rucker:

The Gravity Project has submitted two alternative approaches to include key social determinants of health (SDOH) in the U.S. Core Data for Interoperability (USCDI), version 2, for better care and better health nationwide.

I write to support the Gravity Project submission.

Experts have long known that social and environmental determinants of health explain most of a person’s and population’s health status. The disparities in morbidity and mortality during the COVID-19 pandemic over the last nine months have highlighted this reality, which has been studied and debated for over 40 years in the US and many other countries.

The Gravity Project convened a broad group of stakeholders to achieve a consensus-based set of comprehensive coding standards to capture SDOH in existing EHR systems that now support the work flow of nearly all clinical care. Since its creation, I have observed the Gravity Project providing expert and committed leadership in developing and coordinating a carefully structured, efficient, and comprehensive approach to:

  • Understand the value and use of SDOH data for clinical care and population management;

  • Analyze gaps in existing terminology and codes used to represent SDOH-related activities in clinical delivery settings;

  • Develop standard terminology, vocabulary, and codes to refer to and implement SDOH concepts in a platform-agnostic EHR context.

    I was honored by the invitation (via UCSF, the original sponsor) to join this group. I know from my experience as a strategic planner for health services that the Gravity Project’s

recommendations to add critical domains such as food insecurity, housing instability, transportation insecurity, social isolation, and stress to the USCDI, integrated as platform- agnostic standards by certified EHRs into the core clinical activities of assessment, diagnosis, intervention, and evaluation of outcomes, would make a foundational contribution not only to clinical care but to strategic planning to improve population health. (I have used the SDOH framework for plans for pediatric care in Los Angeles, for Strategic Plans for two California Children and Families Commissions, for establishment of the first Health Action Council at county level in California, and in many other professional and voluntary projects.)

Please see the Gravity Project’s submission dated October 23, 2020 for first, important Background for this SDOH standards work (p.2) and second, detailed description of the Gravity Project nation-wide, public, consensus-building Social Determinants Health Collaborative (p.5).

The Gravity Project submitted two alternative approaches for adding a new data class, Social Determinants of Health, to USCDI version 2. The approaches provide options for consideration by ONC for the structural organization of the new data class, since each approach has strengths that should be carefully considered. I repeat the complete descriptions and rationales here (Gravity Project submission October 23 2020, pp.2-3) to show my whole-hearted support for uptake by the USCDI of this new SDOH data class.

Submission 1: SDOH data class, organized by SDOH domains

The Gravity Project is submitting a new SDOH data class for inclusion in USCDI v2 that will contain functional domains organized to reflect diverse factors that affect health status. The taxonomy of submitted domains are described by Food Insecurity, Housing Instability and Homelessness, Inadequate Housing, Transportation Insecurity, Financial Strain, Social Isolation, Stress, Interpersonal Violence, Education, Employment, and Veteran Status. Additional domains beyond this list will be added in the future, but this list contains domains that the Gravity Project can support for USCDI v2. Each of these domains will contain a repeated set of elements with specific vocabularies for: Assessments (LOINC); Goals (LOINC); Problems/Health Concerns (ICD-10-CM (billing) and SNOMED-CT (clinical)); Interventions (SNOMED-CT and/or CPT/HCPCS); Outcomes (LOINC); and Consent. (See attachment 1 for an outline.) The approach also includes data elements supporting Consent, if and where needed, related to the use and sharing of SDOH data to and among relevant stakeholders.

This approach has the benefit of consistency with and logical evolution of the 2015 Edition Health IT certification criteria. While previously adopted certification criteria specified 8 domains and specific standards (Financial resource strain, Education, Stress, Depression, Physical activity, Alcohol use, Social connection and isolation, and Exposure to violence), the Gravity Project’s submission would be an expansion of prior practice under a newly minted class for SDOH. In addition, the proposed changes broaden the scope of prior vocabularies that limited users to assessment of conditions, but did not specify a standard for other critical activities, including goals, health concerns, interventions, or outcomes. The addition of these standards will enhance interoperability among users that are not only interested in measuring or recording the existence of a condition but documenting and initiating, including ordering, substantive interventions to improve patient health. Should ONC want to consider how these

SDOH submissions would interact with the existing module in the 2015 Edition, we are ready and willing to contribute to this discussion.

Submission 2: SDOH data class, organized by SDOH activities in clinical care

The Gravity Project also submits a new SDOH data class for inclusion in USCDI v2 organized instead by data elements that reference SDOH activities and tools used by some providers in their current clinical care workflows. The data elements in the new SDOH data class, listed along with their appropriate vocabularies will be: Assessments – LOINC; Problems/Health Concerns – ICD-10-CM (billing) and SNOMED-CT (clinical); Goals – LOINC; Interventions – SNOMED-CT (clinical) and CPT/HCPCS (billing); Outcomes – LOINC; and Consent. Each element will contain a taxonomy of SDOH health status (code sets) that can be leveraged to describe conditions across multiple domains (e.g. Food Insecurity, Housing Instability and Homelessness, Inadequate Housing, Transportation Insecurity, Financial Strain, Social Isolation, Stress, Interpersonal Violence, Education, Employment, and Veteran Status). Organizing the SDOH data class by activities that reference the various relevant code panels and profiles for SDOH allows stakeholders to add SDOH domains as consensus is reached on each. (See attachment 2 for an outline.)

By including an externally maintained list of domains, activities and value sets, this approach can accommodate SDOH data domains as they mature and are added. As additional domains, vocabularies, and value sets are published, the hierarchy and nomenclature of the named data elements would remain consistent. The addition of these new standards will enhance interoperability among users and will reduce regulatory lag for updates to USCDI for SDOH domains.

We note that, at the time of submission on October 9, 2020, the Gravity Project will not have completed the full set of gap analysis and code set development, but we expect all to be resolved by the time ONC would make its decision in May-June, 2021, about the final definition of version 2. This tracks the approach ONC took with the social, psychological and behavioral data certification criterion in the 2015 Edition, where ONC noted that some code sets remained to be finished but identified the structural placeholder in the proposed rule and identified the appropriate standard(s) in the final rule.

The Gravity Project submission presented a detailed discussion of the need for and maturity of an SDOH data class to enrich and improve clinical care ((Gravity Project submission October 23 2020, pp.4-5). I will add this additional consideration, based on my six years as a consumer representative on the Board of Directors of DirectTrust:

The pressing need for SDOH documentation standards is equaled by the imperative for their integration into existing workflows. Clinicians eager to assess and document and attempt to improve patients’ live and care cannot be expected to add to the already immense demands on their time and attention. Inclusion by the USCDI of a new class of data - accompanied by standard specifications for terminology, value sets, and a FHIR Implementation Guide to capture, group, and share the results – means that certified EHRs are enabled to design EHR functions that will be useful, understandable, and interoperable. With that push and those specs,

the value of SDOH data collection can move well beyond the clinical setting to public health reporting, research, and population health planning. The time to enhance capability in those realms is now and the need, as dramatized by the current pandemic, is urgent.

Thank you for including the new Social Determinants of Health data class in the USCDI as proposed by the Gravity Project.

Sincerely yours

Lucy Johns M.P.H.
Independent Consultant
Health Care Planning and Policy

ONC-Let Support Gravity Project-USCDI v2_0.pdf

Log in or register to post comments