Submitted By: Grace Cordovano / Enlightening Results | |
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Data Element Information | |
Use Case Description(s) | |
Use Case Description | Under HIPAA's Right of Access (45 CFR § 164.524 https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html), individuals have a right to access PHI in a “designated record set, where the designated record set is defined as a group of records maintained by or for a covered entity comprising: 1) Medical records and billing records about individuals maintained by or for a covered health care provider; 2) Enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or 3) Other records that are used, in whole or in part, by or for the covered entity to make decisions about individuals. Clinical decision support systems (CDSS) and AI-assisted decision-making have become more integrated into patient care, medicine, and healthcare due to Meaningful Use. If CDSS and AI-assisted decision-making may be used to guide patient care, patients should have a right to a copy of the information used to guide their care. This is especially important for continuity of care, for when patients are denied care, treatments, procedures (either by their payor or clinical care team). Patients should have a right to a copy of any CDS data that is generated and used to guide their clinical care, from a right of access standpoint as well as from the point of transparency. |
Estimate the breadth of applicability of the use case(s) for this data element | Unknown |
Healthcare Aims |
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Maturity of Use and Technical Specifications for Data Element | |
Applicable Standard(s) | SNOMED CT https://confluence.ihtsdotools.org/display/DOCCDS/1.+Introduction |
Additional Specifications | https://www.hl7.org/implement/standards/product_brief.cfm?product_id=334 https://www.healthit.gov/isa/sharable-clinical-decision-support |
Current Use | In limited use in production environments |
Supporting Artifacts |
https://www.healthit.gov/isa/sharable-clinical-decision-support |
Extent of exchange | N/A |
Potential Challenges | |
Restrictions on Standardization (e.g. proprietary code) | Unknown |
Restrictions on Use (e.g. licensing, user fees) | Unknown |
Privacy and Security Concerns | The privacy and security concerns about this data element is not unique to this particular type of PHI, thus covered by HIPAA and other governance. |
Estimate of Overall Burden | Unknown |
Other Implementation Challenges | Unknown |
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Data Element |
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Clinical Decision Support Data
Description
Data and reporting used for risk stratification, optimization of patient outcomes, detection of decompensation, clinical and patient education. |
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