Activity performed for or on a patient as part of the provision of care.

Data Element
Procedures Provenance
Description

Procedure provenance defines if the procedure was self-reported by the patient during the visit or completed by the provider.
Submitted By: Rachel Eager / New York eHealth Collaborative
Data Element Information
Rationale for Separate Consideration Provenance is a data class in USCDI however in longitudinal CCDs it is difficult to tell if the procedure was self-reported or performed during that visit. Procedure provenance will add another layer of information to the procedure section.
Use Case Description(s)
Use Case Description When CCDs are combined into a longitudinal CCD it is difficult to tell if a provider is recording a patient’s past procedure in the procedure section or this procedure happened at the time of the visit. If procedure provenance was added as a data element this gives providers looking at a longitudinal CCD more information about whether that procedure was self-reported or happened in that episode of care. This is especially important when this data is being exchanged across many different providers caring for a patient.
Estimate the breadth of applicability of the use case(s) for this data element This would be a level 2 element that would pertain to any patient that has ever received a procedure.
Use Case Description If a patient has self-reported having a procedure in the past this may have been filled out in the procedure section but the patient may have not necessarily gotten that specific procedure. Procedure provenance helps to define this by allowing the provider to categorize this information as self-reported. In other cases, where the procedure is actually completed during the visit this gives another layer of information to the health history of a patient in a longitudinal CCD.
Estimate the breadth of applicability of the use case(s) for this data element This would also be a level 2 element that would pertain to anyone who is having or has had a procedure.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) N/A
Additional Specifications N/A
Current Use Not currently captured or accessed with an organization
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns A procedure provenance is a sensitive element and must be treated as such. Like all patient information, the information captured under procedure provenance should not be shared in a way prohibited by applicable law.
Estimate of Overall Burden This would be an additional element for vendors to add to a CCD under the procedure section so there would need to be a potential build out and a possible upgrade. Providers would then need to start recording this in the procedure section in a patient’s record.
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 0 - Data element is not represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 0 - Data element is captured, stored, or accessed in limited settings such as a pilot or proof of concept demonstration.
Criterion #3
Maturity - Current Exchange		 Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment
Thank you for your submission. Not currently captured or accessed by an organization.

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