Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information

Michelle Dougherty, MA, RHIA, CHP
AHIMA Foundation

Jennie Harvell
Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services

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This report was prepared under contracts #HHSP23320074303EC and #HHSP23320110006EC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the American Health Information Management Association.  For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W. , Washington , D.C. 20201 .  Her e-mail address is: Jennie.Harvell@hhs.gov.

The opinions and views expressed in this report are those of the authors.  They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

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Study Acknowledgements And Contributors

Bob Dolin, MD
Lantana Consulting Group

Gaye Giannone Dolin, MSN, RN
Lantana Consulting Group

Sue Mitchell, RHIA, Consultant

Margaret Williams
AHIMA Foundation

Cyndi Lundberg, RN, BSN
SNOMED Terminology Solutions
College of American Pathologists

Daniel Vreeman, PT, DPT, MSc
Regenstrief Institute, Inc.

Keystone Beacon Community

James Walker, MD, FACP

James Younkin
Geisinger Health System

I. Background

Each year about 12 million medically complex and/or functionally impaired Americans need long-term and post-acute care (LTPAC) services in nursing homes, home health, or other settings. Persons receiving LTPAC services typically have multiple health care encounters with physicians and other clinicians. Transitions to and from LTPAC settings to emergency rooms and hospitals are common.

The need to improve care and care coordination for LTPAC patients is great. For example, about one in four Medicare beneficiaries discharged from a hospital to a skilled nursing facility is readmitted within 30 days.¹ Clinical trials suggest that 20-50 percent of rehospitalizations are preventable. Preventable rehospitalizations and other suboptimal health care outcomes are detrimental to LTPAC patients and costly for federal and state governments as Medicare and Medicaid programs are the primary payers of LTPAC services.² Most persons who receive formal LTPAC services are insured by these programs.

Definition of Interoperability Interoperability in health care is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively and consistently, and to use the information that has been exchanged. National Alliance for Health Information Technology

Health information technology (HIT) and health information exchange (HIE) among providers have the potential to improve the overall quality and continuity of care of LTPAC patients, reduce rehospitalizations, and control health care spending. Yet LTPAC providers do not have robust, interoperable HIT capabilities to support the electronic exchange and use of clinical information. Without these HIT capabilities, LTPAC providers face significant barriers in accessing patients' clinical information from other providers; further, hospitals, primary care professionals, caregivers and other providers cannot obtain timely and important LTPAC information. Ultimately, LTPAC providers' limited HIT capacity and engagement in HIE activities:

• Impedes care coordination and effective transitions of care;
• Retards improvements in the delivery of quality health care;
• Contributes to higher costs for payers and patients, and poor outcomes; and
• Will eventually stymie eligible professionals' and hospitals' ability to qualify for incentives for the meaningful use of HIT.³

Both the Patient Protection and Affordable Care Act (ACA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) aim to improve the quality and efficiency of health care. Many health care reform provisions depend on health care providers' ability to electronically exchange and use clinical information. Although HITECH supports the development of a nationwide HIT infrastructure for the electronic exchange and use health information, to date, limited resources have been directed to support LTPAC providers' participation in HIE activities. Although HITECH did not include financial incentives for LTPAC providers, market-driven pressures arising from payment and delivery reforms are expected to require investments in technology to coordinate care and exchange information with other providers to deliver high quality care in a safe and efficient manner. These pressures will extend to eligible providers (e.g., physicians and short-term acute care hospitals) as they attempt to qualify for their meaningful use electronic health record (EHR) incentive payments; as well as to providers ineligible for such incentives, including nursing homes and home health agencies, as they seek to position themselves in a reformed health delivery environment.

To achieve national health care reform goals, HIT policies and initiatives to advance the electronic use and exchange of health information must include LTPAC. This report describes the:

• Policy rationale for engaging certain LTPAC providers (specifically nursing homes and home health agencies) in HIT activities, and describes activities underway that seek to engage these providers.

• Opportunities to leverage federally mandated assessment instruments as an entrance point for engagement.

• Tools to assist LTPAC providers in expanding their HIT capabilities.

Substantial gains in health care quality, efficiency, and outcomes will be potentially delayed if LTPAC providers do not adopt and use HIT and exchange capabilities. Concrete steps are needed to engage nursing homes and home health agencies and enable them to use HIT that supports electronic exchange across providers. As described later in this report, there is support for adding to future stages of meaningful use requirements that eligible professionals and hospitals have two-way electronic exchanges of clinical information with other providers -- including LTPAC -- in order for those eligible providers to qualify for federal incentives and avoid financial penalties. As hospitals and physicians -- both important referral sources for LTPAC providers -- increase their use of HIT they will exert more pressure on LTPAC providers to use standards-based technology to exchange information and coordinate care.

This report identifies opportunities and tools to support HIT adoption and use among LTPAC providers, particularly nursing homes and home health agencies by leveraging federally required assessment instruments used and electronically transmitted by almost 100 percent of these providers in the United States. The analysis and approach for engaging LTPAC providers in HIE activities result from a four-year study sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (HHS) and undertaken by the American Health Information Management Association (AHIMA) Foundation that involved input and technical expertise from a variety of public and private sector LTPAC stakeholders and experts in HIT and HIE.

The central opportunity presented in this report to engage LTPAC in HIE activities is to apply HIT vocabulary and document exchange standards to existing federally required patient assessment content thus enabling their interoperable exchange and re-use. Clinical and other experts consulted as part of this study indicated that:

• Exchanging patient assessment information could improve communication between care providers and provides an important snapshot of an individual's clinical status at the time the assessment was completed.

• Exchanging a summary of the patient's clinical status derived from each assessment completed provides allows for tracking and trending changes in condition over time and is useful to clinicians and case managers.

• Exchanging a summary of an assessment completed prior to transition may be dated but still provides valuable information since some information is better than no information. (See discussion in the Exchanging Standardized Assessment Content for Patient Assessment Summary Documents section regarding the Keystone Beacon Community Program.)

• Re-using some assessment content could provide clinically useful information to support more complex shared care and transition processes. (See discussion in Opportunities to Re-Use Standardized Patient Assessment Content and Link with Other Data section regarding the inclusion of assessment information in the creation and exchange of the Uniform Transfer Form in Massachusetts, and the creation and exchange of the home health plan of care in New York.)

In summary, an approach to accelerate LTPAC providers' adoption of more sophisticated types of information exchange and sharing capabilities would support meaningful use requirements. The exchange of patient assessment instruments (PAIs) and the re-use of assessment content could serve as the initial foundation for expanding LTPAC providers' HIT capabilities and participation in more sophisticated HIE activities. This report includes the following information and makes available a set of technical tools for LTPAC providers to begin participating in HIE.

• Section II describes the methods and approaches used to conduct this study.

• Section III describes the national policy priorities and the policy rationale for engaging LTPAC providers in electronic HIE activities, highlighting relevant parts of the ACA and HITECH.

• Section IV provides an overview of the HIT capabilities in LTPAC and reviews existing PAIs.

• Section V describes how standardized PAIs and content could be used to engage LTPAC providers in HIE activities. This section describes how interoperable PAIs and content could be used to accelerate LTPAC providers' readiness and ability to participate in the nationwide HIT infrastructure through the interoperable exchange of PAIs and patient assessment summary documents. This section also describes how standardized assessment content is being re-used in a variety of HIE activities.

• Section VI describes the technical infrastructure needed to support an interoperable nationwide health information infrastructure that includes LTPAC and outlines the tools available to facilitate interoperable exchange.

• Section VII discusses opportunities for expanding beyond patient assessments and advancing to more sophisticated types of HIE.

• Section VIII, describes opportunities and options for next steps that could be undertaken to increase the LTPAC sector's and states' awareness of impending demands for electronic clinical information exchange.

II. Study Methods

In 2007, ASPE/HHS contracted with the AHIMA Foundation to advance the interoperable use of HIT and EHRs by LTPAC providers by leveraging federal requirements for the electronic submission of PAIs. The study, building on work that had been undertaken by the Consolidated Health Informatics Initiative and endorsed by the National Committee on Vital and Health Statistics (NCVHS),⁴ involved the identification and application of HIT standards to the Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS) instruments, development of technical tools to support interoperable exchange of assessment instruments and the re-use of assessment content for patient assessment summary documents, identification of opportunities to support the widespread adoption and use of interoperable patient assessment information, and steps needed to advance HIE with and by LTPAC providers.

The AHIMA Foundation subcontracted with several technical experts to assist in linking recognized vocabulary standards to PAIs, develop implementation guides for the interoperable exchange of PAIs, and identify issues that need to be addressed to enable the interoperable exchange of patient assessment summary documents. These technical experts included:

• Lantana Consulting Group, Bob Dolin, MD, and Gaye Giannone Dolin, MSN, RN
• Sue Mitchell, RHIA, HIM and Standards Consultant
• Cyndi Lundberg, RN, BSN, SNOMED Terminology Solutions, College of American Pathologists
• Daniel Vreeman, PT, DPT, MSc, Regenstrief Institute, Inc.
• Keystone Beacon Community, Jim Walker, MD, CMIO and Jim Younkin, Director, Keystone Health Information Exchange
• LTPAC and industry stakeholders as noted in: Appendix A: Stakeholder Interview Summary, and Appendix J: Patient Assessment Summary for Health Information Exchange

To support the opportunities outlined in this report, AHIMA developed 13 Appendices that offer essential background information and technical tools developed as part of the four-year study. Study methods included:

• Conducting stakeholder interviews to discuss incentives for and barriers to HIT adoption and HIE by LTPAC providers. The interviews also explored implications of limited HIT interoperability and gathered insights on how to advance the use and exchange of electronic clinical information in LTPAC settings (see Appendix A: Stakeholder Interview Summary). The stakeholder interviews were instrumental in identifying and developing the opportunities identified in this report.

• Engaging experts to determine a technical approach and interoperability tools for content and exchange standards to be applied to the MDS Version 3 (MDS 3.0) and OASIS.

• Mapping HIT content standards to assessment items and developing a "Rosetta Stone" as a resource for assessment items and their standard representations.

• Engaging experts to identify a subset of assessment content for a summary to provide a clinically relevant snapshot of an individual's status.

• Testing the premise of the study to re-use assessment content to support HIE with a provider and HIE organization.

In addition to the technical tools in Appendices A-L, a list of Terms and Acronyms was compiled that readers may find useful when reading the report (Appendix M: Terms and Acronyms).

III. National Policy Priorities

National policy promotes the use of HIT to advance health care delivery, payment and outcomes. LTPAC providers are a vital part of the health care system and an important part of the nationwide HIT infrastructure. The HITECH of 2009 and the ACA of 2010 establish important goals for the exchange and use of HIT to reform health care. This study collected and analyzed data from multiple sources to generate the findings and opportunities described in this report.

As described in this section, national policy is reforming the health care system with the goals of better quality care, health care outcomes and efficiency. The policy framework uses HIT as a tool that aids improvements in care coordination and transitions of care. National policymakers also have promoted HIT as a critical tool to support new health care delivery and payment systems that will make marked improvements in quality, safety, efficiency, population health and health outcomes. Key strategies to advance the technical HIT infrastructure in the United States include spurring adoption of EHRs, using technical standards and vocabularies, and establishing a mechanism to exchange clinical information electronically. These policies stemmed from the need to accelerate health care providers' EHR adoption and use including HIE.

In the health care system, LTPAC providers deliver specialized care to elderly, frail or disabled patients and to individuals who require ongoing treatment or care following an acute health episode. Figure 1 identifies some of the most common LTPAC providers. Typical services include rehabilitation, medical management, skilled nursing services, and assistance with activities of daily living due physical and/or cognitive impairments. This study specifically focused on two of those LTPAC providers -- nursing facilities/skilled nursing facilities and home health agencies.

FIGURE 1. Common Types of Long-Term and Post-Acute Care (LTPAC) Providers
Nursing facilities or skilled nursing facilities Home health agencies Hospice providers Inpatient rehabilitation facilities (IRFs) " Long-term acute care hospitals Assisted living facilities Continuing care retirement communities Home and community-based services Adult day service providers

The Federal Health IT Strategic Plan lays a foundation for HHS to support adoption of HIT/EHRs in LTPAC by leveraging the 2009 HITECH and the 2010 ACA. Figure 2 provides an excerpt from the Office of the National Coordinator for Health Information Technology's (ONC's) Federal Health IT Strategic Plan.⁵ The next subsections review the policy goals of HITECH and the ACA and their meaning for LTPAC providers.

FIGURE 2: Federal HIT Strategic Plan Excerpt related to LTPAC

HHS will build on meaningful use to adopt electronic standards for the exchange of clinical data among facilities and community-based LTPAC settings, including, where available, standards for messaging and nomenclature. ONC will leverage the State HIE and Beacon Community grant programs in demonstrating methods for which the electronic exchange of information with LTPAC entities can improve care coordination. In addition, HHS will identify opportunities in the ACA to support the use of HIE technologies by LTPAC and behavioral health providers to improve quality of care and care coordination.

Improving LTPAC providers' capacity to participate in HIE could contribute to the success of both the HITECH EHR Meaningful Use Incentives Program and systemic improvements envisioned in health care reform. As observed in the Federal Health IT Strategic Plan 2011-2015:⁶

• The Medicare and Medicaid EHR Incentive program (under HITECH) incentivizes eligible professionals and hospitals to electronically exchange information and states that "requirements for sharing information electronically across provider settings will grow stronger in future stages [of the Meaningful Use Program]."

• The ACA is "an even more important potential driver of provider motivation to exchange information." The delivery system reforms and quality improvements envisioned in the ACA will require richer and timelier information to provide more efficient and coordinated care. These efforts, as well as likely future stages of meaningful use, will rely on emerging HIE models. The strategic plan reflects that: "Eventually, as digital health information becomes more widely available, exchanging it will be more natural and incentives will become less relevant. Several challenges also exist to creating a national infrastructure."

HITECH Focuses on Key Priorities for HIT

To support the development and adoption of a nationwide HIT infrastructure, Congress enacted and President Obama signed the HITECH of 2009. The Act seeks to substantially expand the electronic use and exchange of health information to:

• Improve the quality and continuity of health care, the delivery of health care services, patient health outcomes, and population health;
• Increase efficiencies;
• Decrease costs; and
• Increase overall health care value.

HITECH resources to accelerate the adoption of HIT and EHRs primarily target physicians and acute care hospitals. Several HITECH programs support the electronic exchange and use of health information. These include state-level HIEs and Beacon Community initiatives. A few grantees in both programs are making a deliberate effort to engage nursing homes and home health agencies.⁷

The law also enables eligible professionals (primarily physicians) as well as eligible hospitals to receive Medicare and Medicaid incentive payments for the meaningful use of certified EHR technology. A core goal of meaningful use is the two-way exchange of clinical information among the spectrum of health care providers. Once providers establish electronic exchange of basic clinical information, they can progress to exchanging other clinical information like advance directives and obtaining prescription information for medication reconciliation. Accordingly, meaningful use objectives for electronic exchange become more rigorous each year. To qualify for Stage 1 meaningful use incentives, eligible professionals and hospitals must meet certain measures regarding the electronic exchange of clinical information. Objectives for electronic clinical information exchange are expected to ratchet up in Stages 2 and 3.

Even though LTPAC providers are not eligible for EHR incentive payments, their capacity to exchange health information electronically is likely to impact eligible professionals' and eligible hospitals' ability to qualify for meaningful use incentives. Figure 3 identifies meaningful use Stage 1 objectives that eligible professionals and hospitals could have trouble meeting if LTPAC providers have limited EHR and electronic exchange capabilities. These challenges will likely increase as meaningful use thresholds increase in future stages. Further, beginning in 2015, Medicare eligible professionals and hospitals that do not meet the meaningful use requirements will be subject to downward payment adjustments.

FIGURE 3: Meaningful Use Objectives for Eligible Professionals and Hospitals Impacted by LTPAC Electronic Exchange Abilities
Electronically exchange (i.e., send and receive) key clinical information among providers of care. Provide a summary care record for each transition of care (ToC) or referral. Perform medication reconciliation for individuals who transition into care of an eligible professional or eligible hospital. Record advance directive status upon admission of patients 65 and older in an eligible hospital.

ONC recognizes the importance of including the wide array of health care providers in the emerging nationwide HIE infrastructure. A May 2011 Blog⁸ posted by the ONC states that:

"ONC's core mission includes promoting the meaningful use of health information technology nationwide. By one definition, "meaningful users" are those who qualify to receive funding under the Medicare and Medicaid Electronic Health Records Incentive Programs under the HITECH…. But the incentives do not apply to everyone…[including] mental health providers…[and] long-term and post-acute care providers.

For ONC, the fact that not all providers are eligible for payments under HITECH is a reminder that meaningful use is not only a financial incentive program; it is also a goal. Meaningful use is the idea that all of our nation's health care system will benefit from an IT infrastructure in which electronic health information can be collected, exchanged, and innovatively deployed to improve the safety, quality, and cost-effectiveness of American health care. ONC has several programs and resources to help providers and hospitals that do not happen to be eligible for incentive payments nevertheless use health IT to improve their patients' care."

There are several initiatives underway to engage LTPAC providers in HIT, EHR, and HIE activities at the federal, state and regional level. Some of these initiatives are described below:

• ONC Challenge Grants: In January 2011, ONC announced an additional $16 million in "Challenge Grants" to ten states/SDEs focusing on certain clinical areas, including "improving long-term and post-acute care transitions." The funding for the Challenge Grants supplemented the $547 million in funds that ONC awarded to each state and qualifying Territories to support electronic HIE primarily by Eligible Professionals and Eligible Hospitals participating in the Meaningful Use Program. Through the Challenge Grant program, ONC awarded almost $7 million to the following four states focusing on transitions in nursing homes and/or home health.

  • Colorado: Colorado Regional Health Information Organization is focusing on connecting communities and developing tools to support the workflow for information exchange including LTPAC providers.

  • Oklahoma: Oklahoma is focusing on the technology infrastructure across the state to facilitate the HIE workflow that will avoid unnecessary transfers and coordinate advanced directives.

  • Maryland: Maryland will leverage an operational statewide HIE to share critical pieces of clinical information in real-time as residents of the state's long-term care facilities (LTCFs) transition from one care setting to another. The goal is to connect all 235 LTCFs to the statewide HIE.

  • Massachusetts: Massachusetts is leveraging its state HIE and implementing the Improving Massachusetts Post-Acute Care Transfers (IMPACT) program. The program is developing tools to support decision-making and information sharing at the point of transfer to reduce unnecessary hospitalizations. IMPACT is planning to leverage the ONC Standards and Interoperability (S&I) Framework TOC initiative to coordinate standards development for development of a universal transfer form (UTF) set and the re-use of interoperable, standards-based assessment content to engage LTPAC providers in HIE.

• ONC Beacon Communities: Under the Beacon Community Program, ONC provided grant funding to 17 communities to support building and strengthening their HIT infrastructure and exchange for improved care coordination, quality, and economic efficiency.⁹ Some of the communities have specific initiatives to engage LTPAC providers.

One Beacon Community -- Keystone in Danville, Pennsylvania -- has leveraged the work of this study to engage the nursing home and home care agencies in their community. Their HIE efforts are described in the following section: Exchanging Standardized Assessment Content for Patient Assessment Summary Documents.

In summary, HITECH did not include significant support for the use of EHRs and exchange of health information by LTPAC providers, even though eligible professionals and hospitals will increasingly need electronic clinical information from LTPAC providers to qualify for meaningful use incentives and deliver high quality health care. In the very near term, an approach to accelerate LTPAC providers' adoption of more sophisticated types of information exchange and sharing capabilities could contribute to the development of the technical infrastructure that could support the more robust clinical information exchange anticipated through the meaningful use requirements.

ACA Priorities for Care Coordination Depend on Electronic Exchange of Information

The ACA of 2010 sets in motion changes to reform the United States health care system, improve the quality of care and control costs. Both health care delivery and payment structures are two ACA focal points. Specifically, ACA provisions aim to reduce care fragmentation by promoting delivery and payment improvements that support the continuity and quality of care as patients transition across care settings, reduce hospital readmissions, and curb unnecessary costs. Many ACA provisions seek to enhance collaboration among providers and promote mutual accountability by aligning incentives.¹⁰Table 1 highlights some of the ACA activities that advance the electronic information exchange and the use of HIT including EHRs by LTPAC providers.

TABLE 1. Key ACA Provisions that Impact LTPAC Providers
ACA   Section	Program
2701	Adult health quality measures for Medicaid eligible adults
2704	Evaluate integrated care around a hospitalization
3004	Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs
3006	Plans for value-based purchasing program for skilled nursing facilities and home health agencies including development, selection and modification of measures
3021	Establishment of Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services (CMS) (test and demonstrate new payment and delivery models)
3022	Medicare shared savings program (accountable care organizations)
3023	National pilot program on payment bundling and determination of the assessment instrument (such as Continuity Assessment Record and Evaluation (CARE)) to be used in the pilot program
3024	Independence at home demonstration program
3025	Hospital readmission reduction program
3026	Community-based care transitions program
3502	Community health teams to support the patient-centered medical home
6114	National demonstration projects on culture change and use of information technology in nursing homes
6703	Grant program for adoption and use of certified EHRs by LTCFs (e.g., nursing homes)
6703	Support participation of LTCFs and state HIE programs
6703	Secretary shall adopt and implement content and messaging standards for the exchange of clinical data by LTCFs

A number of ACA reforms extend across the health care continuum to stimulate coordination of care, especially after an acute episode. Service delivery and payment changes will encourage or require hospitals, physicians and post-acute care settings to work together to improve overall health care quality, reduce rehospitalizations and control health care spending.

LTPAC providers play a significant role in achieving ACA goals relating to care coordination and avoidable hospital readmissions because:

• Over a third of all Medicare patients discharged from acute hospitals receive LTPAC services (almost 80 percent are either discharged to skilled nursing facilities or sent home with home health services).¹¹

• A significant portion -- almost one-quarter of Medicare beneficiaries -- discharged to a skilled nursing facility was readmitted to the hospital within 30 days.¹²

ACA Technology-Related Strategies to Improve Coordination and Reduce Rehospitalizations Information exchange Quality and outcome metrics Improved communication Payment bundling

Research is demonstrating that improved information sharing and coordination can impact hospital readmission rates.¹³ Accordingly, the ACA explicitly couples many reforms with the use of HIT and EHRs throughout the health care system, including LTPAC providers. A number of ACA provisions require, when feasible, the electronic exchange of patient clinical information. Other ACA sections mandate use of patient clinical data to measure quality and rely on or encourage the use of HIT to facilitate information sharing and improve care coordination and transitions in care. New Medicare and Medicaid payment methods will use electronic patient clinical data from many different provider types including: skilled nursing facilities, home health agencies, long-term care hospitals, IRFs, hospice and others.

These ACA provisions are expected to create market pressures on LTPAC to improve the quality, continuity, and efficiency of care; and the use of HIT and electronic HIE is expected to be a key enabler of these reforms.

IV. Hit Capabilities in LTPAC

Almost all nursing homes, home health agencies and IRFs are capable of electronically transmitting (one-way) non-interoperable PAIs required by the Federal Government. In addition, some of these LTPAC providers have adopted additional HIT functionality, although few have robust, interoperable EHRs systems with the ability to electronically exchange clinical information with other providers. As a result, LTPAC providers are unlikely to become full participants in the nationwide HIT infrastructure unless steps are taken to engage the sector.

Federally Required Assessment Instruments

As summarized in Table 2, CMS requires three LTPAC providers to complete and electronically transmit specific PAIs (i.e., records with clinical, demographic and other information about a patient). Providers and CMS use data from these instruments for payment, quality monitoring and reporting, patient assessment, and care planning. A fourth instrument is being demonstrated and evaluated.

TABLE 2. Existing Patient Assessment Instruments by Type of LTPAC Provider
LTPAC Type	Patient Assessment Instrument
Nursing Homes	Minimum Data Set Version 3.0 (MDS 3.0)
Home Health Agencies	Outcome and Assessment Information Set (OASIS)
Inpatient Rehabilitation Facilities	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
Comprehensive assessment for post-acute care payment reform demonstration	Continuity Assessment Record and Evaluation (CARE) (demonstration)

The assessment instruments for nursing homes, home health agencies and IRFs are required by CMS to be completed on patients/individuals at various intervals of their stay. The instruments are required to be electronically transmitted each time they are completed in a format specified by CMS. As a result, almost 100 percent of these providers automate and transmit assessments, however, transmission formats are not interoperable (i.e., they do not adhere to accepted HIT formats and content standards) thus limiting the ability to exchange and re-use assessment content.

As part of a Deficit Reduction Act of 2005 demonstration on post-acute care payment reform, CMS developed the CARE instrument for use in this demonstration as a "single standardized patient assessment instrument…to measure functional status and other factors."¹⁴ In June 2011, CMS is required to report the demonstration results to Congress. The ACA also references the use of CARE or a similar instrument to support the national pilot program on payment bundling. Providers would use the instrument to evaluate a patient's condition and help determine the most appropriate care setting.¹⁵

Electronic Information System Capabilities in Nursing Homes and Home Health Agencies

Federal assessment requirements have resulted in LTPAC providers having the information technology capacity to support the maintenance and transmission of required assessments. This section describes what is known about electronic systems capabilities in nursing home and home health agencies. Little research is available regarding the HIT capabilities for IRFs.

FIGURE 4. Nursing Home Electronic Information System Capability in the United States by Percentage of Adoption (2004)
SOURCE: Resnick, H.E., Manard, B.B., Stone, R.I., Alwan, M. "Use of Electronic Information Systems in Nursing Homes: United States, 2004." Journal of the American Medical Informatics Association (JAMIA), 2009, 16: 179-186. Abstract available online at: http://jamia.bmj.com/content/16/2/179.abstract

Nursing homes and home health providers currently use electronic information systems to support some administrative and clinical processes. Figure 4 and Figure 5 illustrate the most common HIT capabilities and adoption percentages. An analysis shows that nursing homes and home health agencies use electronic information systems to support a variety of internal processes. However, findings also show a significant underuse of the clinical capabilities in EHRs once acquired¹⁶ thus widespread use of full functioning EHRs is not yet prevalent in this sector.

FIGURE 5. Home Health Electronic Information System Capability in Home Health and Hospice by Percentage of Adoption (2007)
SOURCE: Resnick, H.E., Alwan, M. "Use of Health Information Technology in Home Health and Hospice Agencies: United States, 2007." Journal of the American Medical Informatics Association (JAMIA), 2010, 17: 389-395. Abstract available online at: http://jamia.bmj.com/content/17/4/389.abstract. * Estimate should be interpreted with caution.

There is growing awareness of the importance of fully interoperable HIT capabilities.¹⁷ LTPAC leaders are conscious of the need for the sector to participate in the growing nationwide HIT infrastructure. Since 2005, a group of LTPAC associations and leaders (known as the LTPAC Health IT Collaborative) has been working together to set priorities, advance HIT, and align the LTPAC sector with national policy priorities. The collaborative publishes recommendations for action for LTPAC providers, policymakers and other stakeholders every two years. The 2010-2012 priorities are as follows:¹⁸

• Leverage existing programs and policies to engage LTPAC providers.

• Certify EHR vendor solutions for LTPAC providers to promote interoperability.

• Advance adoption and use of HIT and EHRs.

• Foster HIE that includes LTPAC.

• Prioritize technology that supports ToC and electronic prescribing to promote care coordination and continuity of care.

• Focus on person-centered health and health care.

• Showcase valuable and effective use of HIT to the LTPAC sector.

• Promote and disseminate research and best practices.

HIT and EHR Certification for Ltpac

HITECH requires the use of certified EHR technology for certain providers (e.g., physicians and short-term acute care hospitals) to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs ("Meaningful Use Programs"). For purposes of the Meaningful Use Programs, two types of certifications can be issued to EHR technology that meets certification criteria adopted by the Secretary of HHS: (1) Complete EHR, or (2) EHR Module. To be eligible for meaningful use incentive payments, eligible hospitals (EHs) and eligible professionals (EPs) must use EHR technology that has been certified by an entity authorized by ONC. To date, six ONC-Authorized Testing and Certification Bodies (ONC-ATCBs) have been authorized to test and certify EHR technology that can be used by eligible professionals and hospitals in the Meaningful Use Programs.¹⁹ For example, EHR certification criteria include (but are not limited to) vocabulary standards (e.g., Systematized Nomenclature of Medicine (SNOMED), International Classification of Diseases (ICD), Logical Observation Identifiers Names and Codes (LOINC)) and content exchange standards (e.g., Clinical Document Architecture (CDA) and Continuity of Care Document (CCD)).

While some EHR technology certification criteria used for the Meaningful Use Program for EPs and EHs would be applicable to the workflow in LTPAC setting, there is growing concern and awareness that not all of the certification criteria are applicable to EHR technology used by LTPAC providers. For example, the capability to plot growth charts or submit to immunization registries would not be a typical feature of a LTPAC EHR technology. Additionally, the adopted EHR technology certification criteria do not reflect the requirements that are uniquely needed by LTPAC providers.

For several years, the LTPAC provider and vendor community worked with Health Level 7 (HL7) (a Standards Development Organization) to produce an EHR Functional Profile for LTPAC. This Profile was used by LTPAC stakeholders and the Certification Commission for Health Information Technology (CCHIT) to identify LTPAC EHR certification criteria.²⁰ It should be noted that the CCHIT LTPAC EHR Certification Program has not been recognized by ONC. While there is significant overlap in the EHR criteria that have been adopted for the Meaningful Use Program and the LTPAC EHR Certification Criteria, there are also differences in the criteria that have been identified in these two programs. This misalignment has created confusion and uncertainty among LTPAC providers regarding whether they should purchase certified EHRs and if so, what type of certified EHR product would support the workflow of the LTPAC provider. ONC is aware of the uncertainties and questions regarding EHR certification confronting LTPAC and other providers that are ineligible under the Meaningful Use Programs and is working with stakeholders to better understand their EHR technology needs.

During the discussion at the 2011 LTPAC HIT Summit at the session on "Moving LTPAC Providers in the Nationwide Health IT Infrastructure," providers and vendors concluded that there is likely a core set of EHR criteria that will be common across all EHR products (e.g., requirements related to privacy/security, medication reconciliation, problem list, etc.).²¹ During this discussion, providers and vendors suggested that ONC consider: (1) meeting with LTPAC providers and vendors to identify what EHR certification criteria are needed to support the workflow in LTPAC; and (2) working with the Meaningful Use Workgroup of the Health IT Policy Committee to identify the types of HIE activities that are needed in and from LTPAC. The Longitudinal Coordination of Care Workgroup (LCCWG) created through the ONC-sponsored S&I Framework (described in more detail below) is beginning to examine the HIT standards needed to support HIE on behalf of persons receiving LTPAC. The HIE activities targeted in this S&I effort are expected to advance the meaningful use of EHRs and shed some light on some of the EHR certification criteria needed by LTPAC providers.

As discussed in the section further in this report "Leverage and Standardize Assessment Content to Engage LTPAC Providers in HIE," experts interviewed noted that there is growing discussion about the need to integrate LTPAC providers in HIE activities to support quality, continuity, and collaborative care (Appendix A: Stakeholder Interview Summary). To support efficient and interoperable HIE, some LTPAC providers and EHR vendors believe that it is important to use EHR products that support at least some of the standards incorporated in certification criteria for the Meaningful Use Incentive Program. As reported at the 2011 LTPAC HIT Summit, some vendors expressed an interest in obtaining certification for their EHR products as either: (1) meeting the meaningful use requirements; and/or (2) complying with the LTPAC CCHIT comprehensive EHR criteria.²² At least one LTPAC vendor has obtained hospital modular EHR certification (through an ONC-ATCB) for their product to support the interoperable and secure exchange of health information such as demographics, problem lists, physician order entry, medication lists, medication reconciliation, and advance directives. This LTPAC HIT vendor and one other have also obtained LTPAC CCHIT EHR certification.²³

To support widespread adoption of appropriate and interoperable EHRs for LTPAC, the LTPAC HIT Collaborative recommended in the LTPAC 2010-2012 Health IT Roadmap²⁴ that policy guidance be provided for the EHR certification criteria needed to enable the exchange of health information between hospitals, physicians and LTPAC providers. The members of the Collaborative believe that such criteria would facilitate HIE with and by LTPAC providers, support the meaningful use of EHRs by a wide array of health care providers, and support the emerging nationwide HIT infrastructure.

At this time the ONC has not established a specialty EHR certification program (e.g., a certification and testing program for EHR products for LTPAC providers (or other specialty providers)) or identified EHR certification criteria that are unique to the workflow requirements in LTPAC or other specialty providers. Establishing such a program or identifying EHR certification criteria is complex, could be costly, and requires careful consideration of the advantages and disadvantages. An objective in the draft roadmap of the recently established LCCWG under the ONC-sponsored S&I Framework is to "develop certification requirements for EHR and LTPAC vendors in anticipation of LTPAC pilots."²⁵

V. Opportunities for Engaging LTPAC Providers in HIE Using Patient Assessments

The approach examined in this report would engage LTPAC providers in developing their capacity to exchange and use electronic clinical information in support of health care reform. It uses the federally required PAIs to establish an initial foundation for interoperability and electronic exchange. Laying the foundation will require developing a technical infrastructure and increasing LTPAC stakeholders' awareness of forthcoming demands.

As described below, the approach described in this report is built upon an existing asset -- the MDS 3.0, OASIS and electronic transmission capacity -- to jump-start the involvement of LTPAC providers in HIE activities. Applying HIT standards to widely used assessment documents and the individual data elements in these instruments creates opportunities for LTPAC to engage in interoperable HIE by re-using and exchanging standardized content in an assessment summary other types of documents.

Federally required PAIs can become an entrance point for LTPAC providers to participate in HIE activities and jump-start their use of more sophisticated interoperable EHRs.

Leverage and Standardize Assessment Content to Engage LTPAC Providers in HIE

As described earlier in this report, LTPAC providers currently use limited but not interoperable information systems for clinical and administrative processes. Further, the sector lacks widespread awareness of the need to invest in and use interoperable EHRs that can support HIE. Experts identified two significant barriers for LTPAC providers to participate in HIE (Appendix A: Stakeholder Interview Summary):

• Most LTPAC providers are not ready and able to participate in interoperable electronic exchange of health information.

• The absence of funding and mandates for HIT/EHR adoption and use by LTPAC providers reduces the business case for investing in HIT. Specifically, stakeholders reported insufficient capital to upgrade existing systems or acquire new products that support electronic exchange of health information. Stakeholders expressed that the exclusion of LTPAC from federal HIT funding and mandates will result in a slower uptake of technology in LTPAC settings.

An alternative approach to jump-starting LTPAC providers' use of more sophisticated, interoperable EHRs is necessary because Congress did not make HITECH EHR Incentive funding available to this sector.

A starting point could be to build upon federally required PAIs that are in an electronic format and are electronically transmitted by LTPAC providers and apply accepted HIT vocabulary and exchange standards to these instruments. The nursing home and home health assessment instruments were selected for this study. The IRF-PAI was not selected given intellectual property constraints associated with the content of the instrument (see Appendix B: Using Patient Assessments to Advance Electronic Use and Exchange of Clinical Data). A benefit of this approach is that it builds on existing capabilities and would engage the majority of LTPAC providers. Once engaged, these LTPAC stakeholders could focus on building and using the technical infrastructure to support more sophisticated types of information exchange and sharing. The technical infrastructure for standardizing assessment content and exchanging this information is discussed in Supporting an Interoperable Nationwide Health Information Infrastructure that includes LTPAC.

Exchanging Standardized Assessment Content for Patient Assessment Summary Documents

While leveraging patient assessment content and making it interoperable might be a low-cost and opportunistic approach to engaging LTPAC provides in HIE activities, it is not perfect for summary information needed at ToC. These assessments are completed at prescribed points in time during a person's LTPAC episode. Nursing home assessments can be up to 89 days old and home health agency assessments can be as old as 59 days. The concept of exchanging not just the full MDS 3.0 and OASIS, but also a more concise summary document (a subset of the most clinically relevant items) emerged from on the expert interviews and discussions with the Keystone Beacon Community.

Clinical advisers to this study indicated that: (1) having dated information was better than having no information; and (2) assessment documents include data elements that are likely to be stable over time and clinically relevant at times of transitions/shared care. While less ideal for ToC, submitting patient assessment summary information to an HIE organization each time the MDS and OASIS is completed provides valuable information to support care coordination, shared care and case management processes.

Content for the MDS and OASIS assessment summary was identified as part of this study with input from clinicians (i.e., nursing home and home health agency providers, representatives from hospitals and integrated delivery systems, physicians, and nurses) (see Appendix J: Patient Assessment Summary for Health Information Exchange). The Keystone Beacon Community will be piloting the exchange of interoperable patient assessment summary documents using the HIT content standards identified and linked, under this study, to the MDS 3.0 and OASIS. Document exchange specifications for the exchange of assessment summary documents are under development at Keystone Beacon Community and their vendor partner GE, as well as in the ONC S&I Initiative LCCWG. The Keystone Beacon Community and the ONC S&I Initiative LCCWG are using the MDS 3.0 and OASIS Rosetta Stone resources developed under this study (see Appendix D: MDS Rosetta Stone Spreadsheet, Appendix E: OASIS Rosetta Stone Spreadsheet, Appendix K: MDS Assessment Summary Rosetta Stone, and Appendix L: OASIS Assessment Summary Rosetta Stone).

Diagram 1 illustrates the information flow for bringing almost all nursing homes and home health agencies into HIE activities in a cost-effective manner. In this scenario, non-HIT sophisticated LTPAC providers (they do not presently use interoperable HIT/EHR products) could transmit the federally required PAIs to the HIE organization who could transform it into an interoperable document and/or assessment summary that would be made available to authorized users.

DIAGRAM 1. Exchanging Interoperable Assessment Content by a Non-HIT Sophisticated LTPAC Provider

The top half of Diagram 1 shows the current state of HIE for most nursing homes and home health providers where federally required assessments are electronically transmitted to CMS. This exchange uses a format specified by CMS rather than industry-accepted HIT content and exchange standards (i.e., the assessment exchange is not interoperable).

The bottom half of Diagram 1 shows:

• How the LTPAC provider could transmit the same non-interoperable patient assessment document that is transmitted to CMS to a HIE organization.

• The HIE Organization could:

  • Transform the non-standard CMS assessment document into an interoperable assessment document (i.e., link the assessment items with HIT content standards); and/or
  • Generate an interoperable Patient Assessment Summary Document (a subset of assessment items that clinical experts indicate would be clinically useful to exchange at times of transitions in care and/or shared care).

• The HIE Organization could make available the standardized assessment document and/or the Patient Assessment Summary Document to authorized entities (such as physicians, hospitals, other LTPAC providers, patients/family members).

Opportunities to Re-Use Standardized Patient Assessment Content and Link with Other Data

HIE activities are emerging in federal programs, state and private-sector initiatives that involve LTPAC providers. Some of these activities are using resources developed under this study by re-using standardized assessment content to support other types of interoperable HIE. These activities, briefly described below, can provide steps to increasingly sophisticated HIT use by LTPAC providers building from standardized assessment content:

• Exchange of Transfer Documents. Massachusetts received a Challenge Grant from ONC to advance interoperable HIE on behalf of LTPAC providers. Through this Challenge Grant, Massachusetts is leveraging their state HIE and implementing the IMPACT program. The program is developing tools to support decision-making and information sharing at the point of transfer to reduce unnecessary hospitalizations. The Massachusetts IMPACT program is working with the Longitudinal Care Coordination Workgroup of the ONC S&I Initiative to identify standards needed for the exchange of an interoperable UTF. The Massachusetts IMPACT program anticipates re-using a subset of interoperable MDS and OASIS assessment content to partially populate the interoperable UTF. The re-use of assessment content is expected to support HIE when individuals transfer from LTPAC providers to acute care hospitals, and between LTPAC providers. In addition, the Massachusetts IMPACT program envisions re-using a subset of standardized MDS 3.0 and OASIS assessment data to support HIE with patients and family members.²⁶

• Exchange of Home Health Plan of Care. The New York e-Health Collaborative is advancing work in collaboration with Visiting Nurse Services of New York (VNSNY), physician practice groups, and other stakeholders to create an interoperable plan of care document for home care that would be continuously updated and shared between the home care agency and a physician. The plan of care document that will be standardized in the NY project is the "485 form" formerly required by CMS and remains in widespread use by home health agencies. Although originating in New York, this project is gaining state and vendor support around the United States. The project is advancing its work through the Longitudinal Care Coordination Workgroup of the ONC S&I Initiative to identify and harmonize vocabulary and exchange standards. The VNSNY anticipates re-using a subset of interoperable OASIS assessment content to partially populate the interoperable home health plan of care.

• Detecting potential adverse drug reactions (ADRs). The University of Pittsburgh in Pennsylvania developed and evaluated a consensus list of laboratory, pharmacy, and MDS signals that can be used by EHR systems in nursing homes to detect potential ADRs. The results suggest that ADRs can be detected in nursing homes with a high degree of accuracy using an electronic clinical event monitor that employs a set of signals created from electronic laboratory, pharmacy, and MDS data.²⁷ This type of clinical decision support tool uses lab, pharmacy and MDS data to generate alerts of potential ADRs. While this electronic clinical decision tool has not been standardized, content standards are available for medications, laboratory results and as described in this study, MDS data.²⁸ The availability for content standards for lab results, medications and MDS data, could be used to develop standardized clinical decision support tools targeting ADR monitoring and prevention.

As LTPAC providers become more sophisticated in their HIT use (they use interoperable HIT/EHRs), it is anticipated that standardized assessments, assessment summaries and other information will be exchanged. Diagram 2 depicts how nursing homes and home health agencies could exchange interoperable assessment documents/summaries and supplement it with additional EHR data (e.g., medication information) as their use of standardized technology becomes more mature.

DIAGRAM 2. Exchanging Interoperable Assessment Content by a More HIT Sophisticated LTPAC Provider

The top part of Diagram 2 shows the same current state of HIE for most nursing homes and home health providers as depicted in Diagram 1 (i.e., electronic transmission of non-interoperable federally required assessments from the provider to CMS). The middle of Diagram 2 depicts the "more HIT sophisticated" LTPAC provider using their software to:

• Transform the non-standard CMS assessment document into an interoperable assessment document by linking the assessment items with HIT content standards and transforming it into the HL7 CDA format (an industry-accepted exchange format).

• Generate a Patient Assessment Summary Document (using accepted HIT content and exchange standards) and possibly linking additional EHR data (such as medication data) to the Patient Assessment Summary Document.

• Transmit these documents to the HIE Organization or directly to the receiving provider/patient/family member. If transmitted to the HIE Organization, the organization would make this information available to authorized entities.

Building on the standardized assessment content and exchange formats developed under this study, LTPAC providers will be positioned to more readily implement the advancements envisioned by the Massachusetts IMPACT program, New York e-Health Initiative and others to improve information sharing and re-use.

VI. Supporting an Interoperable Nationwide Health Information Infrastructure That Includes LTPAC

In order for the interoperable exchange of assessment content to occur in the manner illustrated in Diagram 1 and Diagram 2 above, a technical approach and tools would have to be developed consistent with HITECH requirements and industry standards. This study, in consultation and collaboration with several technical experts (see Study Methods for names of experts), examined and identified both content and exchange format standards for the MDS and OASIS instruments and content for patient assessment summary documents that could be an entrance point for interoperable HIE on behalf of LTPAC providers. The standards are explained in the next subsections.

To leverage the MDS or OASIS assessment instrument, LTPAC providers need a technical infrastructure and tools that are consistent with HITECH requirements and existing industry standards.

Content Standards for MDS and OASIS Assessment Instruments

For the MDS or OASIS content to be interoperable (machine-readable), the assessment instruments must be linked to existing content standards and vocabularies. Interoperable content facilitates the efficient re-use of assessment data in different EHR systems and across different applications in a single EHR product. Experts reviewed the MDS and OASIS and identified the following content standards applicable data elements in the instruments:

• Logical Observation Identifiers Names and Code (Clinical LOINC®), used for common laboratory tests and clinical observations.

• Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT), a comprehensive clinical terminology.

• International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM); for future implementation, ICD-10 relates to the 10th edition.

• HL7 administrative code sets for gender and marital status.

The content standards mapped (linked) to the individual MDS and OASIS items were compiled in a Rosetta Stone spreadsheet for each instrument (Appendix D: MDS Rosetta Stone Spreadsheet, and Appendix E: OASIS Rosetta Stone Spreadsheet). The Rosetta Stones used the CMS data dictionary for the assessment items and provides a reference by MDS and OASIS item to the applicable LOINC name and code, SNOMED concept and code, ICD-9-CM code and/or ICD-10-CM code. The process and mapping rules for developing the Rosetta Stones are discussed in detail in Appendix C: Rosetta Stone Mapping Guidelines and Heuristics.

Clinical experts used the MDS and OASIS Rosetta Stones to identify a clinically relevant subset of items for the Patient Assessment Summary Documents. Stakeholders were solicited to identify an initial set of items which were validated through a consensus process. The process for identifying and validating the subset of items in the assessment summary is discussed in Appendix J: Patient Assessment Summary for Health Information Exchange. Based on the input from clinical stakeholders and experts, Rosetta Stones were also created for the MDS and OASIS Patient Assessment Summary Documents (Appendix K: MDS Assessment Summary Rosetta Stone, and Appendix L: OASIS Assessment Summary Rosetta Stone).

Exchange Architecture for the MDS and OASIS

The ability to exchange patient assessment information will require LTPAC providers to use the standardized exchange formats that are widely accepted by the industry. Lantana Consulting Group was engaged to recommended and develop technical tools to support the exchange of interoperable MDS and OASIS assessment content. There are two primary exchange formats recommended for the MDS and OASIS:

• Health Level 7 Clinical Document Architecture (HL7 CDA) is a standard that allows clinical documents and its content to be exchanged.

• Health Level 7 Continuity of Care Document (HL7 CCD) is a form of the CDA standard that is focused on the most relevant administrative, demographic, and clinical information about a patient. It is based on the American Society for Testing and Materials E2369-05 Standard Specification for Continuity of Care Record and provides a means for one health care provider to summarize patient data and forward it to another provider to support continuity of care.

To enable the interoperable exchange of assessment instruments, Lantana Consulting Group facilitated the development and balloting of a new HL7 CDA standard for assessment instruments (HL7 Implementation Guide for CDA Release 2: CDA Framework for Questionnaire Assessments, Release 1 standard²⁹). This implementation guide highlights the application of this standard to the MDS 3.0 as an example.

To ensure providers and vendors are able to properly convert and validate non-interoperable MDS 3.0 to an interoperable format consistent with the HL7 CDA implementation guide for Patient Assessments, Lantana developed technical tools focusing on the MDS 3.0.

Lantana Consulting Group provided guidance on using the CCD exchange format for summary records. Although technical tools were not developed under this study, the work is being advanced by the Keystone Beacon Community and under the S&I Framework Longitudinal Coordination of Care Patient Assessment Summary Document Sub-Workgroup (see Advancing the Technical Infrastructure through the S&I Framework for more information on the initiative).

 

Summary of Technical Tools and Resources Developed

This study developed several tools, highlighted in Table 3, to facilitate the application, widespread use, and dissemination of content standards related to the MDS or OASIS assessment information.

TABLE 3. Resources to Support Application of Content and Exchange Standards to MDS and OASIS
Implementation Resource	Description	Appendix
Content Standardization
Rosetta Stone Mapping Guidelines and Heuristics	This resource offers the guidelines and rules that were used to map recognized HIT vocabularies -- specifically, LOINC® and SNOMED CT -- to the MDS and OASIS assessments, and the use of coded vocabularies in an HL7 messaging standard (the CDA Patient Assessment Questionnaire Implementation Guide) to enable the interoperable transmission of these assessments. The exchange standard enables assessments to be represented as intended by assessment developer (using a "model of use" format) and enables the re-use of assessment content (i.e., using the model of meaning format).	C: Rosetta Stone Mapping Guidelines and Heuristics
MDS 3.0 Rosetta Stone	This resource maps each MDS 3.0 question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for nursing home EHR vendors and HIE organizations.	D: MDS 3.0 Rosetta Stone
	The MDS value set of diagnosis concepts file provides a set of SNOMED concepts to illustrate how the MDS problem/diagnosis section could be semi-populated from the EHR.	D: MDS Value Set of Diagnosis Concepts
OASIS Rosetta Stone	This resource maps each OASIS question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for home health EHR vendors and HIE organizations.	E: OASIS Rosetta Stone
Rosetta Stone for MDS Assessment Summary	A technical resource in Excel which identifies the MDS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.	K: MDS Assessment Summary Rosetta Stone
Rosetta Stone for OASIS Assessment Summary	A technical resource in Excel which identifies the OASIS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.	L: OASIS Assessment Summary Rosetta Stone
Exchange Format Standardization
Current Standards Landscape	A discussion about the current standards and their application to assessment content and enabling re-use of health information. This resource could be used by LTPAC providers and vendors to facilitate their awareness and understanding.	F: Current Standards Landscape
Interoperability Toolkit	This appendix document provides a summary of the technical tools available in the toolkit.	G: Interoperability Toolkit
HL7 CDA Implementation Guide	This guide describes how to represent questions and answers in PAIs as an HL7 CDA document. The implementation guide represents the MDS 3.0 as an example of a CDA patient assessment document.	G: Interoperability Toolkit CDA Implementation Guide for Assessment Instruments
MDS Conversion/ Validation Utilities	Various tools for transforming the MDS from a CDA format to the CMS transmission format and tools to validate the conversion.	G: MDS Transform Tool and Validator
CCD Guidance and Considerations	This document provides general information on how to design a valid CCD document using patient assessment content from the MDS.	G: MDS CCD Design Document
Standards Development and Adoption Recommendations	Provides recommendations for advancing and accelerating the use of HIT and EHRs in the LTPAC industry based on existing standards and known gaps. Discusses the relationship of existing and potential national policy strategies in relating to the standards recommendations.	H: Standards Development and Adoption Recommendations

Advancing the Technical Infrastructure through the S&I Framework

The content and exchange standards that have been applied to PAIs and the resources summarized in Table 3 are being used in the ONC S&I Initiative. The LCCWG has been created as a community-led initiative to support HIE on behalf of LTPAC stakeholders and address potential gaps in the S&I Transitions of Care work products to support engagement of LTPAC providers in HIE activities. The LCCWG has established three sub-workgroups. Each of these three sub-workgroups has expressed their intent to re-use standardized MDS and/or OASIS assessment data to support their use. The following describes the workgroup charges:

1. Patient Assessment Summary Document Sub-Workgroup³⁰

   1. Validate and refine, as needed, a subset of MDS 3.0 and OASIS content that could be clinically useful to exchange with hospitals, physicians, other LTPAC providers, and/or family members. The subset that of MDS 3.0 and OASIS content that will be targeted is that which was identified through this ASPE study (see Appendix K: MDS Summary Rosetta Stone; and Appendix L: OASIS Summary Rosetta Stone).
   2. Re-use the standardized MDS 3.0 and OASIS assessment content provided by this ASPE study (see Appendix D: MDS 3.0 Rosetta Stone; and Appendix E: OASIS Rosetta Stone).
   3. Provide input and guidance on the transformation tool being developed by the Geisinger Keystone Beacon Community to transform the non-interoperable MDS 3.0 and OASIS into an interoperable clinical document that can be made available for HIE.
   4. Develop a CDA implementation guide and schema leveraging work under way by the Geisinger Keystone Beacon Community to enable the interoperable exchange of Patient Assessment Summary Documents.
   5. Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.

2. Longitudinal Care Plan Sub-Workgroup³¹

   1. Validate and refine, as needed, the content that is to be included on the home care POC (formerly 485-form).
   2. Identify content and format standards needed to represent content of the home care POC (formerly 485-form). The Sub-Workgroup will take into account and re-use previous standards identified through the ToC Initiative for the home care POC (formerly 485-form).
   3. Re-use, as feasible, standardized OASIS assessment content provided by this ASPE study (see Appendix E: OASIS Rosetta Stone).
   4. Keep aware of and provide feedback on the standards being identified and piloted by the VNSNY, home care electronic medical record vendors, home care agencies, and hospitals/physicians exchanging an interoperable home care POC (formerly 485-form).
   5. Develop a CDA implementation guide and schema leveraging work under way by the VNSNY home care POC pilot to enable the interoperable exchange of home care POC (formerly 485-form).
   6. Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.

3. LTPAC Care Transition Sub-Workgroup³²

   1. Develop a priority list of acute/post-acute transitions based on volume, clinical instability and acuity of the required information.
   2. Develop standard clinical content defined by the receiving clinicians for all high-priority transitions.
   3. Develop resources to support interoperability of all clinical content across all sites of care.
   4. Re-use of selected data elements from OASIS and MDS to populate the transitions data sets from home health agencies and skilled nursing facilities/extended care facilities.

The three sub-workgroups of the Longitudinal Coordination of Care initiative are expected to use standardized content from assessment instruments to support LTPAC's inclusion in HIE and improve shared care and transitions. Standardizing the MDS and OASIS creates the foundation for LTPAC providers and vendors to build more sophisticated, interoperable HIT systems.

Issues Requiring Further Consideration

Individuals served by LTPAC providers often have chronic illnesses and disabilities resulting in physical and cognitive functional limitations. They interact routinely with multiple providers. The ability to communicate functional status between providers and caregivers is crucial to ongoing care planning and treatment. This study calls out an important gap that could be addressed by the industry.

Currently there is not a uniform definition, assessment method or scale for functional status to be communicated consistently across care settings. This creates challenges for representing functional status in a standardized vocabulary to support continuity of care, information exchange and re-use. Functional status information is important to assessing an individual's level of functioning and providing appropriate and needed health and supportive services. Functional status impacts the individual's quality of life, wellness, and ability to care for self, and is often a factor in public and private payment methodologies as well as in quality management and clinical outcome measurement.

Work is needed to enable the inclusion of functional status content to support the meaningful use of EHRs across the health care continuum. Specification of the HIT content and messaging standards related to functional status will enable the exchange of critical information to support quality and continuity of care.

Appendix I: Recommendations for Functional Status provides more specific suggestions for addressing the standards related to functional status.

VII. Next Steps - Engaging States And LTPAC Providers

This report describes many important initiatives under way that are building the infrastructure for LTPAC providers to become meaningful users of HIT and participate in HIE activities.

National Governors Association (NGA) Issue Brief: HIT Integration in Long-Term Care There is great promise for electronic exchange of health information to reduce fragmentation, especially for long-term care patients. It can improve the quality of care delivery and is a potential mechanism for reducing health care costs by reducing duplicative tests and services. Many LTCFs already use technology in their care settings, but connecting with broader state HIE efforts is just beginning. Although states understand the value of integrating HIT and long-term care, many challenges remain.33

ASPE is funding additional work, to be completed in 2012, of the HIE activities underway in state and other programs that target LTPAC (and behavioral health) providers and identify gaps, barriers, and opportunities to advance HIE and the use of HIT by these providers. This work includes:

• Conducting an environmental scan of ONC State HIE grant and Beacon Community Programs, state Medicaid programs, and other initiatives to identify HIE activities underway and/or needed that focus on LTPAC (and behavioral health) providers, including identifying opportunities that could support quality and continuity of care through the efficient re-use of standardized assessment content.

• Identifying and supporting the adoption of content and messaging standards, implementation specifications and EHR certification criteria needed to engage LTPAC and behavioral health providers.

• Using the HIT Policy and Standards committees and ONC's standard-setting framework (the S&I Framework) to support and accelerate electronic HIE and use by LTPAC and behavioral health providers.

• Identifying a method/mechanism to maintain and update HIT standards linked to PAIs as these instruments and standards evolve over time.

• Identifying and addressing gaps in HIT standards needed to support HIE on behalf of LTPAC and behavioral health patients (e.g., functional and cognitive status).

Additional activities to advance HIE on behalf of LTPAC providers include understanding and overcoming the issues and challenges states and LTPAC providers face.

Engage States

The changes on the horizon for delivery and payment of health care services including LTPAC necessitate changes in how information is shared across the health care spectrum. A number of efforts are underway to support states' ability to engage LTPAC in exchange activities and address the challenges discussed above. A number of state grant programs highlight the need to address LTPAC or focus funding.

• ONC State HIE Cooperative Agreement Program: Through ONC, states were eligible for grants to facilitate the secure movement of health information using nationally recognized standards. The grants supported the development and implementation of a state HIT plan to support the exchange and use of health information in the state and focus efforts primarily on those provides eligible for meaningful use incentive payments. Fifty-six states and territories were eligible and received grants.³⁴

• ONC Challenge Grants: As described in section III: HITECH Focuses on Key Priorities for HIT, ONC issued four Challenge Grants to states to focus on improving LTPAC transitions. These efforts can provide a model to other states for engaging LTPAC in HIE.³⁵

• ONC Beacon Community Cooperative Agreement Program: As described in section III: HITECH Focuses on Key Priorities for HIT, ONC awarded 17 grants to several communities to use HIT and HIE capabilities to improve care coordination, quality of care and slow growth of care spending. A few Beacon Community Programs -- Rhode Island, Maine and Pennsylvania -- include a focus on LTPAC providers. Pennsylvania's Geisinger Keystone Beacon is focusing on connecting their community including nursing homes and home health agencies to improve care coordination, quality and efficiency by using the Patient Assessment Summary discussed in section V: Exchanging Standardized Assessment Content for Patient Assessment Summary Documents.³⁶

• CMS State Medicaid HIT Plans (SMHPs): As part of the HITECH Medicaid Incentive Program, state Medicaid agencies were directed to begin conversations with a range of stakeholders to develop solutions for how the Medicaid EHR Incentive Program will operate in the context of larger health systems and statewide efforts. States were asked to develop an SMHP which serves as the Medicaid HIT vision document. The SMHP integrates the statewide HIT plan developed under the ONC grant program and contains at least four components: A current landscape assessment, a vision of the state's HIT future, specific actions necessary to implement the EHR incentive program, and an HIT roadmap. To accomplish this plan, states will initiate discussions and activities with a diverse group of individuals, organizations and institutions from within the state government (including long-term care) and with persons outside the state government.³⁷

Other tools and resources have been developed or are under development to assist states with addressing how to engage LTPAC in HIT plans and HIE activities. ONC posted a "Vulnerable Population Report" on the State HIE Resources web site.³⁸ The Vulnerable Population Report, produced by ASPE and private sector representatives, describes LTPAC (and behavioral health) population and providers, how states could engage these providers and support the meaningful use program and eligible providers and eligible hospitals.

Further, ONC sponsored a five-year study with the NGA Center for Best Practices to better understand the states' HIE needs with respect to long-term care. NGA conducted a technical expert panel meeting and coordinated meetings with state HIT officials in conjunction with ONC Regional Extension Center and Beacon Communities meetings. NGA published an issue brief summarizing the findings and concluded that there is great promise for electronic exchange of health information for improving quality and potentially reducing health care costs once LTCFs begin connecting to broader state HIE activities.³⁹ The NGA issue brief highlighted the following common challenges identified by states to integrate long-term care into HIE efforts:^{40, 41}

• Lack of funding/payment incentives to adopt HIT and EHRs: States have generally prioritized their focus on incentivized providers. Although they understand the value of engaging LTPAC providers, the path to greater integration is largely unclear and not uniform among states.

• Inaccessibility of data: Inadequate information in an inconsistent structure is a significant barrier. Clinical data in LTPAC is often fragmented due to antiquated record systems that collect only a portion of a patient's health information. Information such as the MDS is reported to CMS in real-time, but that data cannot be shared across care providers and may not include all relevant information.

• Workforce issues: To effectively use and deploy HIT, staff in LTPAC settings need to be skilled and well trained. The ability to attract skilled information technology workers is a challenge. The information technology workforce in LTPAC frequently has high turnover rates and typically lower education and health care training.

• Lack of standardization of EHRs: There is a lack of standardized data collection methods in the various LTPAC settings that leads to challenges in care coordination functions such as treatment history, referrals and transfers. CCHIT has certified EHR programs unique to LTPAC but adoption by LTPAC vendors has been low.

• Multiple and competing state health initiatives running in parallel: States are coordinating multiple initiatives including sustaining Medicaid, implementing health care reform, and controlling health care costs. As a result, state HIT efforts have largely focused on the meaningful use incentive program for eligible providers and hospitals. The result has been fewer resources for ineligible providers such as LTPAC.

As part of its study on integrating long-term care in HIT, the NGA noted that despite the challenges, states are taking steps to engage LTPAC providers and made the following recommendations to states:⁴²

• Understand the LTPAC Environment and Engage Stakeholders: NGA recommended that states conduct an environmental scan of LTC facilities, providers, care centers and others to understand their landscape and key challenges. For example, some states have conducted a survey of the LTPAC providers and their readiness/interest in HIE activities. States could bring LTPAC stakeholders into workgroups and planning efforts to identify specific actions for change.

• Incorporate Long-Term Care into Ongoing State Strategic HIT Plans: States could look for opportunities to establish goals and bring LTPAC into their state strategic and operational plans as well as their HIE outreach plans.

• Utilize Regulatory and Policy Levers: States could use their regulatory process to develop and advance HIE across the state including LTPAC; attempt to drive the market using purchasing from state programs and Medicaid; and convene payers to make a case for better integration of long-term care and HIE to help push the market toward adoption.

In addition, ONC has convened meetings to raise awareness about the need to exchange health information across the health care enterprise, including the LTPAC sector. ONC convened a town hall meeting at the 2011 LTPAC HIT Summit⁴³ to make available information regarding state HIE activities that include LTPAC providers. In October 2011, ONC and private sector foundations hosted a working meeting -- Putting the IT in TransITions⁴⁴ -- of innovators, policymakers, and HIT experts, providers, and others to identify how HIT could be used to support some of the challenges in transitions in care. In addition, in November 2011, ONC hosted a meeting for State Health IT Coordinators, Beacon Communities, and other entities. A session during this meeting was focused on increasing awareness of and opportunities and methods for engaging LTPAC providers in HIE activities.

The work developed under this study and described in this report provides important information, resources and tools that states could leverage to address some of the challenges identified by the NGA and advance HIE on behalf of LTPAC patients and providers. As described, the MDS 3.0 and OASIS are electronic data sets collected on persons served by most nursing homes and home health agencies. When content and exchange standards are applied to the MDS 3.0 and OASIS assessments, the data can be re-used and shared with other health care providers in an efficient and cost-effective manner. The ability to exchange other clinical information (such as medication information) beyond the MDS and OASIS is a critical step, and can be linked with widely available assessment information to support more robust HIE opportunities.

Engage LTPAC Providers

As the NGA observed in their issue brief, "many LTC facilities already use technology in their care settings, but connecting with broader state HIE efforts is just beginning."⁴⁵ The lack of availability, adoption and use of interoperable EHRs by the LTPAC providers is a critical barrier. The stakeholder experts interviewed as part of this study believe HITECH and the ACA will alter market pressures and eventually force LTPAC providers to adopt EHRs and HIT, albeit at a slower rate than had incentives been made available to these providers (Appendix A: Stakeholder Interview Summary). At this time, LTPAC providers have limited awareness of ongoing HIT activities and the anticipated increase in HIE demands. This lack of understanding could threaten quality and continuity of care improvements envisioned in health care reform and ultimately the viability of the LTPAC provider in the new emerging health care delivery systems.

CMS recognizes the need to support LTPAC providers in the adoption and use HIT. Towards this end, CMS is planning a special project as part of its 10th scope of work for the quality improvement organization program. The special project will seek to support the use of HIT by health care providers that are ineligible for EHR incentive payments. The project will support and encourage the meaningful use of HIT to improve quality and continuity of care.

In addition, the LTPAC HIT Collaborative⁴⁶ and its member organizations are considering and/or pursuing several activities to address some of the challenges the LTPAC sector is experiencing. The Collaborative is:

• Engaging provider, professional, and vendor associations that serve the LTPAC community to prioritize interoperable HIT and HIE for their members through several activities including:

  • Development and implementation of strategic initiatives that focus on participation in national, state and local HIT/HIE activities; and
  • Delivery of educational efforts that focus on EHR use and the imperative for engaging in HIE.

• Connecting with policymakers (federal and state) to align the HIT and HIE priorities including advancing the:

  • Use of certified EHRs for and by LTPAC providers; and
  • Interoperable HIE on behalf of persons who receive LTPAC services.

• Publishing an updated LTPAC Health IT Roadmap for 2012-2014 that promotes the use of HIT/EHRs and participation in HIE activities to support quality, continuity and coordination of care. The Collaborative will advance the new Roadmap and priorities at the 2012 annual LTPAC HIT Summit. The updated Roadmap will:

  • Align priorities and activities in the ONC 2011-2015 Federal Health IT Strategic Plan;
  • Advance the readiness of the LTPAC sector in using technology to support health care reform goals; and
  • Serve to inform public and private sector entities engaged in health care reform activities about how technology can be used to support the inclusion of LTPAC in service delivery system changes and quality improvement activities.

VIII. Conclusion

The value of LTPAC providers adopting HIT and engaging in HIE is widely accepted yet challenges must be overcome. While the LTPAC provider is presently not eligible for CMS EHR incentive payments, it is arguably in the interests of eligible hospitals and eligible professionals to exchange information with LTPAC providers (in order to meet meaningful use requirements). Further, it is in the interests of LTPAC providers to participate in HIE activities to support quality and continuity of care, and engage in new service delivery models emerging through health care reform. The ONC and ASPE continue to direct resources to advance the participation in HIE activities by LTPAC providers, including supporting the dissemination and use of the free tools developed under this study. Work is needed to extend these tools and enable additional opportunities for the re-use of standardized assessment content to improve quality and continuity of care in LTPAC.

The goals of HITECH and ACA cannot be achieved without successfully engaging LTPAC providers in HIT and HIE policies and initiatives. Leveraging federally required PAIs and patient assessment summary documents provides a cost-effective entrance point for this sector to participate in interoperable HIE through the nationwide HIT infrastructure and build a pathway towards more sophisticated HIE and meaningful use of EHRs. There will be some costs of converting the non-interoperable assessments into interoperable assessment documents and/or re-using interoperable assessment content for various purposes, and at this time it is unclear who will bear these costs. These costs could be borne by the provider and/or organizational HIE entities (e.g., state HIT grantees, Beacon Community programs, etc.). The HIE entity may (or may not) charge a fee for the transformation and exchange of this content. Nonetheless, because this approach builds from currently available electronic health information the cost is expected to be relatively modest.

Implementation of the approach and interoperability tools provided in this report creates an opportunity and strong foundation for LTPAC providers to begin using modern technologies to take steps to improve the quality and coordination of care in today's fragmented health care environment and achieve the seamless information sharing envisioned with health care reform.

Appendices

The appendices provide essential background information, documentation, and tools to support the approach proposed in this report. Several provide the research and in-depth technical analyses that form the backbone of this study. These include a summary of stakeholder interviews (Appendix A) and the environmental assessment of the existing standards landscape (Appendix F). Appendices B through E offer the methods and results of careful technical analyses of existing standards for application with PAIs. Two appendices (Appendix H and Appendix I) provide more details about the recommendations for needed HIT standards. Appendix G is a practical implementation toolkit for LTPAC providers and vendors. Appendices J through L provide guidance on the patient assessment summary. Appendix M provides a glossary of key terms and abbreviations used in this report.

A: Stakeholder Interview Summary

Summary of stakeholder interviews conducted to discuss incentives for and barriers to adoption. The interviews also explored implications of limited HIT interoperability and gathered insights on how to advance the use and exchange of electronic clinical information in LTPAC settings. The stakeholder interviews were instrumental in developing the approach identified in this report.

B: Background Report on Intellectual Property and the Dissemination of Standardized Federally Required Patient Assessments

This report identifies and evaluates potential intellectual property issues that emerge and need to be considered with the application of HIT content standards to federally required assessment instruments. Assessment instrument developers should consider intellectual property implications that will arise with the free dissemination of HIT content standards that will be necessary to facilitate re-use and exchange of assessment information.

C: Rosetta Stone Mapping Guidelines and Heuristics

This resource offers the guidelines and rules that were used to map recognized HIT vocabularies -- specifically, LOINC® and SNOMED CT -- to the MDS and OASIS assessments, and the use of coded vocabularies in an HL7 messaging standard (the CDA Patient Assessment Questionnaire Implementation Guide) to enable the interoperable transmission of these assessments. The exchange standard enables assessments to be represented as intended by assessment developer (using a "model of use" format) and enables the re-use of assessment content (i.e., using the model of meaning format).

D: MDS Rosetta Stone Spreadsheet

This resource maps each MDS 3.0 question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for nursing home EHR vendors and HIE organizations.

MDS Value Set of Diagnosis Concepts

The MDS value set of diagnosis concepts file provides a set of SNOMED concepts to illustrate how the MDS problem/diagnosis section could be semi-populated from the EHR.

E: OASIS Rosetta Stone Spreadsheet

This resource maps each OASIS question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for home health EHR vendors and HIE organizations.

F: Current Standards Landscape

A discussion about current standards and their application to assessment content and enabling re-use of health information. This resource could be used by LTPAC providers and vendors to facilitate their awareness and understanding.

G: LTPAC Interoperability Toolkit and Tools

This appendix document provides a summary of the technical tools available in the toolkit.

CDA Assessment Implementation Guide for MDS and Tools

This guide describes how to represent questions and answers in PAIs as an HL7 CDA document. The implementation guide represents the MDS 3.0 as an example of a CDA patient assessment document.

MDS Transform Tools and Validator

Various tools for transforming the MDS from a CDA format to the CMS transmission format and tools to validate the conversion.

MDS CCD Design Guide

This document provides general information on how to design a valid CCD document using patient assessment content from the MDS.

H: Standards Development and Adoption Recommendations

Provides recommendations for advancing and accelerating the use of HIT and EHRs in the LTPAC industry based on existing standards and known gaps. Discusses the relationship of existing and potential national policy strategies in relating to the standards recommendations.

I: Recommendations for Functional Status

Defines functional status in the context of HIT standards and the importance of the data to support the continuity of care for persons with chronic illnesses and disabilities. Recommends an approach for addressing gaps in standards to address functional status content and representation.

J: Patient Assessment Summary for Health Information Exchange

Describes the project and methodology for developing a patient assessment summary for the MDS and OASIS in collaboration with Keystone Beacon Community.

K: MDS Assessment Summary Rosetta Stone

A technical resource in Excel which identifies the MDS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.

L: OASIS Assessment Summary Rosetta Stone

A technical resource in Excel which identifies the OASIS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.

M. Terms and Acronyms

A resource that lists the terms and acronyms used in this report.

Appendix A: Stakeholder Interview Summary

Summary

Expert interviews were conducted via conference call in May and June 2010 to gather input from stakeholder groups pivotal to advancing the use and exchange of electronic clinical information in LTPAC settings. Participants in the interviews included:

• Post-acute and long-term care (LTPAC) providers.

• Integrated delivery system providers.

• Clinical information system software vendor representatives.

• Staff from the Centers for Medicare and Medicaid Services.

• Members of the federal advisory committees (FACAs) and workgroups addressing Health IT (i.e., the HIT Policy Committee and its committee workgroups and the HIT Standards Committee and its committee workgroups -- Participants did NOT speak for the FACA Committees, the Committee Workgroups, or the ONC).

• Representatives of state-level health information exchange initiatives.

• Staff and committee members from the National Quality Forum.

The following topics were addressed with all stakeholder groups and are detailed more fully in of this appendix:

• Meaningful Use
• Health Information Exchange
• CDA for Transfer of Care
• Data Re-Use
• CDA Tools
• Standards
• Quality Measures
• Functional Status

High level themes that emerged across the stakeholder interviews include:

1. There is an overall lack of readiness and ability to participate in electronic exchange of health information on the part of LTPAC providers.

2. The exclusion of LTPAC from federal HIT funding and mandates will result in a much slower uptake of technology in this care setting. Absent funding and mandates, LTPAC providers generally do not feel they have the capital to invest in upgrading existing systems or acquiring new products that support electronic exchange of health information.

3. There are competing views regarding whether LTPAC providers will want to electronically exchange information if it cannot be reused in their systems. General consensus over several discussion groups was that, even if LTPAC providers are only able to view information, it is a starting point and there is value in the information exchange. However, the information must be efficiently consumable by the clinician.

4. LTPAC is an important component to achieving meaningful use (MU) and distributed health information exchange.

5. Although there are neither direct financial incentives nor MU requirements for LTPAC participation in electronic exchange of information, changing payment models (e.g., bundling, Accountable Care Organizations (ACOs)) and wider use of technology by Eligible Hospitals/Eligible Professionals will create other business drivers for HIT adoption in this care setting.

6. A number of LTPAC organizations operate multiple facilities located in different counties or states. When faced with exchanging electronic information with multiple HIEs, the importance of standardized information becomes critical to any scalability within these organizations.

A more detailed accounting of themes identified through the expert interview sessions are found in this appendix.

Interview Process And Participants

Expert interviews were conducted via a series of 60 minute conference calls in May and June 2010. The investigation team identified categories of stakeholders knowledgeable about advancing the use and exchange of electronic clinical data in LTPAC settings. Key experts from the various stakeholder groups were then identified and contacted to participate in the interview process. The stakeholder groups and interview participants are listed below in Table A-1.

TABLE A-1: Stakeholders and Interview Participants
Stakeholder Group -- Post-Acute and Long Term Care (LTPAC) Providers
Tom Check Senior Vice-President & Chief Information Officer Visiting Nurse Service of New York	John Derr, RPh Strategic Technology Consultant Golden Living
Peter Kress Vice President & Chief Information Officer ACTS Retirement-Life Communities, Inc.	Bill Russell, MD Vice-President & Corporate Medical Director Erickson Living
Renae Spohn, MBA, RHIA, CPHQ, FAHIMA, FNAHQ Director of Clinical Applications The Evangelical Lutheran Good Samaritan Society	Rustan (Rusty) Williams Vice President, Information Services/Technology Systems and Chief Information Officer The Evangelical Lutheran Good Samaritan Society
Stakeholder Group -- Integrated Delivery System (IDS) Providers
Denni McColm Chief Information Officer Citizen's Memorial	Jim Walker, MD, FACP Chief Health Information Officer Geisinger Health System
Stakeholder Group -- Clinical Information System Software Vendors
Andy Brigant Chief Product Officer Point Click Care	Dan Cobb Chief Technology Officer Health MedX
Robert C. Davis CEO Optimus EMR	Doc DeVore Vice President - Product Strategy MDI Achieve
Dave Wessinger Chief Technology Officer Point Click Care
Stakeholder Group -- Centers for Medicare and Medicaid Services (CMS)
Judy Tobin, MBA, PT Project Officer, CARE Instrument Development Office of Clinical Standards and Quality Quality Measurement and Health Assessment Group
Stakeholder Group -- Federal Advisory Committees (FACAs) and Their Workgroups Addressing Health IT
Christopher G. Chute, MD, Dr PH Professor & Chair, Biomedical Informatics Mayo Clinic College of Medicine Member, Health IT Standards Committee	John Derr, RPh Strategic Technology Consultant Golden Living Member, Health IT Standards Committee
Scott White Assistant Director, HIT Policy Labor Representative 1199 SEIU Training and Employment Fund Member, Health IT Policy Committee	Larry Wolf, MS Health IT Strategist Kindred Healthcare Alternate for Richard Chapman (Kindred Healthcare), Health IT Policy Committee
NOTE: These participants did NOT speak for the FACA Committees, the Committee Workgroups, or the ONC.
Stakeholder Group -- State-Level Health Information Exchange (HIE) Initiatives
Phil Magistro Deputy Director, Program Implementation State Government HIT Coordinator Governor's Office of Health Care Reform Pennsylvania	Chris Manning Director of External Affairs Delaware Health Information Network
Andrew VanZee, MHA, FACHE Statewide Health IT Director Indiana
Stakeholder Group -- National Quality Forum (NQF)
Don Casey, MD, MPH, MBA, FACP Chief Medical Officer and VP Quality Chief Research and Academic Officer Atlantic Health	David Gifford, MD, MPH Director of Health Rhode Island Department of Health
Howard Goldberg, MD Director, Clinical Informatics Development Partners Healthcare	Gerri Lamb, PhD, RN Emory University Nell Hodgson Woodruff School of Nursing Atlanta, GA
Larry Wolf, MS Health IT Strategist Kindred Healthcare

The investigation team identified the following topics to be addressed with all stakeholder groups:

• Meaningful Use
• Health Information Exchange
• Clinical Document Architecture (CDA) Standard for Transfer of Care
• Data Re-Use
• CDA Tools
• Standards
• Quality Measures
• Functional Status

Investigators anticipated that the nature and focus of the discussions would vary across each stakeholder group. Thus, a slate of open-ended questions related to these topics was then crafted to capture the unique perspectives of each stakeholder group (see Table A-2 for a sample slate of questions). The topics and questions were presented to the participants for their review prior to the interview.

TABLE A-2: Sample Slate of Interview Topics and Questions: Providers
Topic	Questions
Meaningful Use	Do you anticipate that hospital and physician requirements for MU measures will impact LTPAC? If so, how?
Health Information Exchange	How do you see that HIT can best help your institution(s) streamline information exchange and reporting? What information is important for an LTPAC organization to exchange (send and receive)? What are the barriers/challenges that keep LTPAC from exchanging information with unaffiliated providers and/or HIE organizations now? What steps/activities are needed to overcome these barriers/challenges?
CDA for Transfer of Care	Do you currently send and receive electronic clinical and summary documents? If yes, are they standardized for exchange? Have you thought about standardizing transfer of care patient summary documents? Do you think it is important to use a CDA template/CCD for the creation and exchange of a transfer of care summary document with other providers? To what extent does your EHR have a CDA application? If no current CDA application, what priority is this being given?
Data Re-Use	Should MDS or OASIS data be reused in a transfer of care CDA/CCD? If yes, which content in an MDS/OASIS would be most relevant to reuse in a transfer of care CDA/CCD? If no, why not? Should EHR data be reused in a transfer of care summary CDA/CCD? If yes, which EHR data content would be most relevant to reuse in a transfer of care CDA/CCD? If no, why not? Can you reuse transfer of care/summary information that you've received from another provider in the EHR? In the MDS/OASIS? Which content?
CDA Tools	What technical assistance and/or other support do you need for the interoperable exchange of assessments and summary documents?
Standards	Are there gaps in the CCD standard that impedes the exchange of important LTPAC content for a transfer of care summary? What are the areas where LTPAC needs assistance/guidance in implementing a CCD? In your view, are there gaps in HIT standards for LTPAC that need to be addressed? In your view, what are the barriers to implementing existing HIT standards for LTPAC?
Quality Measures
Functional Status	What are your current challenges to capturing functional status information? What steps/activities are needed to overcome these barriers/challenges? What are your current challenges to capturing cognitive function information? What steps/activities are needed to overcome these barriers/challenges? What type of functional status/cognitive function information do you want to see in a CCD? In addition to questions from the MDS or OASIS, what additional functional status information do you use or need? In addition to questions from MDS or OASIS, what additional cognitive status information do you use or need? Is there a framework for representing functional status and cognitive functioning concepts? Given that there is no single definition of functional status and that multiple concepts are used, what steps are needed to identify a nationally accepted definition of “functional status” and advance the interoperable exchange of content related to functional and cognitive status?

A separate 60 minute conference call was conducted for each stakeholder group interview (a total of eight calls were conducted). A member of the investigation team facilitated participants’ discussion of the slate of topics and open-ended questions. Follow-up questions from investigation team members and interview participants were encouraged.

Discussions by Topic

Topic: Meaningful Use

Stakeholders were asked to discuss their opinions regarding the impact on the LTPAC provider community of the CMS Meaningful Use (MU) requirements for Eligible Hospitals (EH) and Eligible Professionals (EP).

Themes from stakeholder group discussions are as follows:

TABLE A-3: Meaningful Use
Stakeholder Group	Discussion Themes
LTPAC Providers	Although Stage 1 MU criteria do not require EP/EH to electronically exchange information with LTPAC providers, opportunities exist for: LTPAC providers to solicit information exchange with hospitals/physicians if the interoperability standards required by MU are deployed by the LTPAC clinical information system. LTPAC providers to work with acute care providers, HIEs, and hospital/ambulatory EHR vendors to gain agreement on relevant information to be made available electronically during transitions of care across provider settings.
IDS Providers	While there is no direct financial incentive to electronically exchange information in the LTPAC setting: As EP/EH adopt technology, there will be more requests for LTPAC providers to exchange information electronically. Efficiencies experienced by participants in electronic exchange of information will push the curve for adoption. As a by-product of MU, there will be more electronic exchange of data at transfers of care with providers not affiliated with the IDS -- both in-bound and out-bound. New, low-cost exchange models will emerge that recognize the benefits to providers of intermediate steps in information exchange (e.g., providers can view information even if they don’t contribute information to the exchange; clinic notes can be typed in Word and submitted to an HIE to apply a CCD wrapper).
Software Vendors	The exclusion of LTPAC providers from MU will have a negative impact on the adoption of technology in this care setting. LTPAC providers are a very pragmatic group -- most actions are the result of a mandate, an incentive, or a compelling business driver. The fastest way to promote electronic exchange of information is with money and education. Despite the absence of federal incentives for adoption of technology, forward looking LTPAC providers will recognize the need to prove viability in a changing landscape: Participation in electronic exchange of information is an indicator of a progressive provider. Deployment of technology will impact the ability of a provider to recruit younger staff (who will expect and want computers). Efficiency is critical with the ever increasing demands to do more with fewer dollars. There are competing views regarding whether LTPAC providers will want to electronically exchange information if it cannot be reused in their systems. Even if LTPAC providers are only able to view information, it is a starting point and there is value in the information exchange.
CMS	The readiness of LTPAC providers to participate in electronic information exchange is very low. Information garnered through the Continuity Assessment Record and Evaluation (CARE) Health Information Exchange Project (HIEP) -- a project engaging three advanced health information organizations (HIOs) with many members -- shows there is very little exchange of data amongst providers. HIO members were surveyed regarding readiness to exchange information and what type of data they had the ability to either send or consume. Results showed minimal readiness or ability to exchange information. The exclusion of LTPAC from federal HIT funding and mandates will result in a much slower uptake of technology in this care setting. Absent funding and mandates, LTPAC providers generally do not feel they have the capital to invest in upgrading existing systems or acquiring new products that support the electronic exchange of health information.
FACAs	LTPAC is an important component to achieving the advantages of meaningful use and distributed health information exchange such as: avoiding errors, reducing complications, anticipating treatments and interventions, reducing resource expenditures (e.g., re-hospitalization, Emergency Room utilization and similar types of metrics) Absent federal financial incentives, it is important to look for other motivators or enablers that promote HIT adoption and electronic exchange of information by LTPAC providers such as: New payment models (e.g. Accountable Care Organizations (ACOs), payment bundling) necessitate accurate and timely communication of health information for efficient and effective coordination of care. Resources such as the open-source versions of all IHE (Integrating the Healthcare Enterprise) components which allow vendors to easily embed those technologies in their products and reduce the cost of product development. Incremental deployment of technology, (e.g., deploying the ability to receive and read a CCD even though a system does not have the data and/or ability to create a CCD).
State-Level HIEs	Though LTPAC providers are excluded from meaningful use, inclusion of these providers in electronic information exchange is important due to: The significant impact of LTPAC on health care costs and quality (e.g. re-hospitalizations, Emergency Room visits). The need to support MU criteria such as medication reconciliation, transfer of care record and certain quality measures that where LTPAC data is needed for computation of the measure.
NQF	Though LTPAC providers are excluded from meaningful use, inclusion of these providers in electronic information exchange is important due to: MU criteria that look at the exchange of information, National focus on transitions of care Payment reform models that look at bundled payments, ACOs, etc. While process metrics that measure the occurrence of CCD/information exchange are likely for the foreseeable future, the metrics need to transition to outcome measures to be truly meaningful.

Topic: Health Information Exchange

Stakeholders were asked to discuss their opinions regarding what information was important to exchange and the benefits/challenges to exchanging the information. Themes from stakeholder group discussions are as follows:

TABLE A-4: Health Information Exchange
Stakeholder Group	Discussion Themes
LTPAC Providers	Standards are needed to support the exchange of information of particular interest to LTPAC providers such as: Reason for referral Treatment goals Actual treatment orders While exchange of medication information is a high-value action, challenges related to data messaging and data content still exist that preclude automation of the reconciliation process such as: Differences in the completeness of data made available when different versions of NCPDP standards are used by providers, pharmacies, data aggregators, etc. to transport medication information Lack of information on medications that are not part of the pharmacy enterprise (e.g., OTC medications purchased out-of-pocket) NDC codes
IDS Providers	Points of divergence regarding the value of exchanging computable information versus human readable information: Making human-readable information available gets you 85% of the value of an electronic exchange proposition -- most clinicians feel a human-readable, current document is far better than nothing. Questionable value to receiving an electronic “viewable only” form of information that is currently provided as hardcopy. If all the provider receives is electronically viewable information, it stills needs to be reduced to paper/printed for inclusion in the resident record in accordance with standards of practice for recordkeeping.
Software Vendors	Currently there is very little electronic information exchange -- especially with transfers of care. Providers see the value of information exchange -- the sell needs to be on “standardized” exchange. Vendors get many requests for one-off interfaces. High value information to exchange for LTPAC providers includes: demographics, medications, reason for hospitalization (diagnoses), and plan/orders for services on discharge Barriers to LTPAC participation in electronic information exchange include: Technical complexity and ambiguity of some aspects related to exchange of a CCD. (NOTE: Since the interviews were conducted initiatives are underway such as the Green CDA to reduce the complexity) Lack of a standardized approach for electronic information exchange across individual HIEs becomes very problematic for large multi-state national chains. Vocabulary standards are currently inadequate and not readily deployable.
CMS	Proof of concept trial launched with Regenstrief, Healthbridge, and MedVirginia to move Continuity Assessment Record and Evaluation (CARE) data from an HIE to CMS. A subset of CARE data is exchanged using HITSP C83. Data collection for the demonstration slated for June through December 2010.
FACAs	Regarding incremental interoperability (such as a Level 1 CDA with an embedded pdf), the following philosophies from the Mayo Clinic Beacon project were shared: Exchanged electronic data must be put in front of the physician in the context of their native EMR, which means the data must be machineable, manipulatable, and manageable. Physicians involved in routine primary care are fearful of receiving non-standard, difficult to interpret, unfamiliar layout, information. High value information such as labs, meds, allergies and problems, MAY be appropriate to exchange in a human readable format -- but it must be efficiently consumable by the clinician.
State-Level HIEs	New efforts underway in Delaware, Indiana and Pennsylvania to explore how LTPAC providers can be included and serviced by the HIEs.

Topic: CDA to Transfer of Care

Stakeholders were asked to discuss the use of CDAs for transfer of care. Themes from stakeholder group discussions are as follows:

TABLE A-5: CDA to Transfer of Care
Stakeholder Group	Discussion Themes
LTPAC Providers	LTPAC Providers need to closely look at how electronically exchanged information is identified, reconciled, and incorporated into the workflow of the interdisciplinary team. In the instance of a CCD, three key use cases to address in relation to workflow are: Transfer of care Shared care Exchange with the consumer
Software Vendors	LTPAC clients have not requested CCD functionality from participant vendors. One of four participating vendors had the capability of generating a CCD -- all other vendors had road mapped the functionality.

Topic: Data Reuse

Stakeholders were asked to discuss the reuse of MDS/OASIS data for transfer of care summaries. Themes from stakeholder group discussions are as follows:

TABLE A-6: Data Reuse
Stakeholder Group	Discussion Themes
Software Vendors	Concern was voiced over the latency of MDS data If MDS content is used in populating the CCD, the MDS date would need to be front and center so that recipient would be clearly aware if the information was 3 months old. If MDS question(s) are replicated elsewhere in EMR system, there - may be a more current response to use in populating the CCD MDS questions could be useful for CCD but probably not sufficient

Topic: Standards

Stakeholders were asked to discuss any gaps or other issues that impede the deployment of HIT standards.  Themes from stakeholder group discussions are as follows:

TABLE A-7: Standards
Stakeholder Group	Discussion Themes
LTPAC Providers	A number of LTPAC organizations operate multiple facilities located in different counties or states. When faced with exchanging electronic information with multiple HIEs, the importance of standardized information becomes critical to any scalability within these organizations.
Software Vendors	LTPAC vendors and providers will require guidance and assistance with the deployment of standard terminologies such as LOINC and SNOMED.

Topic: Quality Measures

In light of the quality measures incorporated into the Meaningful Use rule, participants were asked to discuss the state of quality measures in the LTPAC setting. Themes from stakeholder group discussions are as follows:

TABLE A-8: Quality Measures
Stakeholder Group	Discussion Themes
National Quality Forum (NQF)	Current LTPAC quality measures based on federal assessment instruments do not adequately reflect the more global perspective of patient-centered care across providers. NQF Care Coordination principles can serve as a foundation for looking more globally across an episode of care that is not defined by the health care setting, but by the success of interventions to achieve better health. The principles are listed in the 2006 NQF document “NQF Endorsed Definition and Framework for Measuring Care Coordination” available at: http://www.qualityforum.org/projects/care_coordination/2006_care_coordination_framework.aspx The NQF Care Coordination web page is available at: http://www.qualityforum.org/projects/care_coordination.aspx

Appendix B: Background Report on Intellectual Property Issues and the Dissemination of Standardized Federally-Required Patient Assessments

The research described in this report was conducted by library staff of the Foundation of the American Health Information Management Association for the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (HHS), under contract no. HHSP2332007430EC.

The content of this publication does not necessarily reflect the views or policies of ASPE or HHS.

Executive Overview

In 2007, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (HHS) contracted with the AHIMA Foundation to perform several activities related to standardizing federally-required post-acute care (PAC) assessments to support interoperable health information exchange. A primary goal of the project was the application of health information technology (HIT) standards adopted by the Consolidated Health Informatics (CHI) Initiative to two of the assessment tools currently mandated by the Centers for Medicare and Medicaid Services (CMS) for reimbursing PAC. These instruments are:

1. the Resident Assessment Instrument (RAI), including the Minimum Data Set (MDS), used in nursing facilities, and
2. the Outcome and ASsessment Information Set (OASIS), used by home health agencies (HHAs).

These two instruments, along with the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), used by CMS for payment in inpatient rehabilitation facilities (IRFs), are standard data collection tools for particular care settings, designed to collect and submit information to CMS according to the agency's electronic submission requirements. The data collected, however, are not comparable across settings, are not standardized using interoperable vocabularies in support of health information exchange, require different and sometimes proprietary formats for reporting based on care setting, and frequently do not interface with a patient’s electronic health record (EHR).

The CHI Initiative, which was transferred to the Federal Health Architecture (FHA) within the Office of the National Coordinator for Health Information Technology (ONC) in 2006, was an effort to establish messaging and vocabulary standards allowing federal agencies to exchange information efficiently and effectively in order to provide better care and lower administrative costs. CHI standards were considered for use through the public/private processes of the Healthcare Information Technology Standards Panel (HITSP), convened by the American National Standards Institute (ANSI) in 2005 under contract to HHS to administer ONC's standards harmonization initiative.

In 2006, the CHI recommended for adoption, across the federal health enterprise, HIT standards defining requirements for exchanging and reusing standardized, federally-required patient/client assessments for functioning and disability. These recommended standards were subsequently approved by the National Committee on Vital and Health Statistics (NCVHS) and the Secretary of the HHS, and forwarded to ONC. The adoption of the CHI-endorsed standards for disability and patient assessment (along with ones for allergy and multi-media) in federal HIT systems was announced in a Federal Register notice published in late 2007.^a

The purpose of the specific project task addressed in this report was to explore the intellectual property (IP) issues associated with the three assessment tools mandated by CMS for PAC reimbursement, investigate the implications of disseminating CHI-standardized MDS, OASIS and IRF-PAI assessment data sets, and develop recommendations for the future dissemination of HIT-encoded instruments.

IP issues with respect to these three assessment instruments vary as to the degree of restriction placed on the use of the data sets and tools within them. All three data sets were initially created with the aid of grant or contract money from the U.S. government. The developers of these data sets claim, or have in the past claimed, some ownership in the assessment instruments. Although work created under grant from or contract with the U.S. government can be copyrighted by the award recipient, government agencies generally reserve the right to use the work for government business, and to authorize others to do so.^b

The RAI/MDS is in the public domain, but only in the United States. Version 2.0 of the RAI/MDS, currently in use, was developed by the Hebrew Rehabilitation Center for Aged (HRCA) under a contract with the Health Care Financing Administration (HCFA), predecessor to the CMS. Lead authors on the 1995 edition of the User's Manual for the RAI version 2.0 were from HRCA and HCFA.^c The 2002 update to the User's Manual for 2.0 appears to have originated within CMS. A number of individuals are acknowledged, many of whom appear to have been members of the MDS Coordinating Team within CMS.^d Outside of the United States, the interRAI Association, a group of researchers in the field of long-term health care, claim the copyrights to version 2.0 of the RAI/MDS. InterRAI registered the copyright to the 1995 edition of the user manual for version 2.0, although they allow it to be used and copied freely within the United States. Version 3.0 of the MDS, currently scheduled for implementation in October 2010, represents a major revision to the assessment tool. This version appears to have originated within CMS, with considerable input from outside experts in long-term care (LTC) issues. The tool was evaluated and validated through a contract with the RAND Corporation, with principal investigators from RAND and the Harvard Medical School Department of Health Care Policy. The final version of the MDS 3.0 item set and data specifications were published by CMS in October 2009. Parts of the RAI manual for version 3.0 were published in November 2009 with the complete manual expected to be available in early 2010.^e While CMS has reported there will be no restrictions on the use of the MDS 3.0 and accompanying tools for the purpose of reporting to assessment data to CMS, it is unclear whether other IP issues might arise. Two screening tools that are integrated into MDS 3.0 are copyrighted. The Regenstrief Institute has received permission from the copyright holder of the Confusion Assessment Method (CAM) tool to incorporate that tool into the Logical Observation Identifiers Names and Codes (LOINC) database, and has previously worked with Pfizer in order to incorporate the Patient Health Questionnaire (PHQ) depression scales into LOINC.^f

Early versions of the OASIS (OASIS A, B, B-1) were developed by the Center for Health Services and Policy Research at the University of Colorado with funding from HCFA, the Robert Wood Johnson Foundation, and later the New York State Department of Health. Prior to 2008, rights to the OASIS instrument were retained by the Center for Health Services and Policy Research. As of late 2007, the OASIS data set had moved into the public domain, and permission to copy or use was no longer required. CMS contracted with Abt Associates and subcontractors at the University of Colorado Health Sciences Center and Case Western Reserve University in 2006 to revise the OASIS data set, resulting in OASIS-C, which HHAs began using in January 2010.^g While it appears there are no longer any IP issues attached to the OASIS data set itself, some of the tools available, but not required, for use with OASIS-C are copyrighted, in particular the Pfizer PHQ depression scales.^h As mentioned in relation to the MDS, Regenstrief Institute has worked with Pfizer in the past to secure permission to use the PHQ screening tools in LOINC.

MDS and OASIS data sets currently in use are available through the Unified Medical Language System (UMLS) of the National Library of Medicine (NLM) and Regenstrief Institute's LOINC database. There are slight differences in the license agreements for using these two instruments through the UMLS, primarily related to the additional restrictions placed on the use of the RAI/MDS outside of the United States. The copyright claims to the MDS and OASIS data sets as represented in LOINC are spelled out in the RELMA (Regenstrief LOINC mapping assistant). The versions of MDS and OASIS in the UMLS Metathesaurus are extracted from LOINC and not necessarily an exact representation of the original source. Since MDS and OASIS are updated in each Metathesaurus release along with LOINC, it is expected that MDS 3.0 and OASIS-C will be available when the version of LOINC containing the new versions of OASIS and MDS is available.ⁱ

The IRF-PAI was developed and validated through a combination of government grants, contracts, and license agreements with the University of Buffalo Foundation Activities, Inc. (UBFA) and the RAND Corporation. HCFA contracted with RAND to evaluate the feasibility of using the Functional Independence Measure (FIM^j) as the foundation piece for the prospective payment system (PPS) for IRFs. UDSMR^®, a division of UBFA, claims exclusive ownership of the Functional Independence Measure (FIM), the core of the IRF-PAI, trademark rights to FIM^®, and compilation rights to the IRF-PAI training manual.^k Due to UDSMR^®ownership claims, anyone other than a facility subject to the Medicare payment system who wishes to use the IRF-PAI can only do so through a license agreement with UDSMR^®. The FIM has not been incorporated into either the UMLS or LOINC.

Both interRAI and UDSMR^® have created assessment instruments for additional PAC settings, and are clearly aware of government mandates to utilize instruments that can work across multiple settings. Also, the recent revision of the OASIS data set was undertaken in part so that the data collected are more in alignment with the assessment data collected in other PAC settings. Given additional mandates arising out of the CHI Initiative, particularly the one requiring future federalhealth information acquisitions be based on CHI standards, instrument developers may be interested in participating in HIT standardization activities in order to remain relevant as the movement toward interoperability and standardization continues to gather steam.

References

CENDI Copyright Task Group. (2002). Frequently Asked Questions About Copyright: Issues Affecting the U.S. Government. Oak Ridge, TN: CENDI Secretariat, Information International Associates, Inc. Retrieved from http://www.cendi.gov/publications/04-8copyright.html#41.

CHI (2006). Standards Adoption Recommendation -- Functioning and Disability. Accessed January 2008 at http://www.ncvhs.hhs.gov/061011p2b.pdf.

HHS. "Additional Consolidated Health Information (CHI) Health Information Technology Standards" 72 Federal Register71413-14 (December 17, 2007). Accessed January 2008 at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gp….

Kramer, Andrew, et al. Case Studies of Electronic Health Records in Post-Acute and Long-Term Care. (Washington, DC: HHS, ASPE, Office of Disability, Aging and Long-Term Care Policy, 2004. Accessed January 2008 at http://aspe.hhs.gov/daltcp/reports/ehrpaltc.htm.

Wark, Cynthia G., et al. "Government Issue: CHI Lays the Groundwork for Federal Data Exchange." Journal of AHIMA75, No.8 (September 2004): 36-38. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15455567.

Introduction And Background

Federal Efforts at Defining Interoperability Standards

The CHI Initiative was a federal effort with a goal of establishing messaging and vocabulary standards to allow federal agencies to exchange health information efficiently and effectively in order to provide better care and lower administrative costs.¹ In 2006, the CHI Initiative was transferred to the FHA within the ONC, now an agency of the HHS. The FHA worked closely with the Health IT Policy Council (HITPC), which brought together entities within HHS and other federal agencies to advance short and long-term HIT policy.

In 2006, the CHI recommended for adoption, across the federal health enterprise, HIT standards defining requirements for exchanging and reusing standardized federally-required patient/client assessments for functioning and disability. The HIT standards approved were then presented to and approved by the NCVHS, and were subsequently approved by the Secretary of HHS, who forwarded them to the ONC.²

In late 2007, the adoption of the Disability and Assessments standards were one of three new domain areas and associated clinical standards announced in the Federal Register:

Disability and Assessments:

• Regenstrief Institute, Inc LOINC^© (Logical Observation Identifiers Names and Codes^©)^l representation and codes for questions and answers on federally-required assessment forms;
• CHI-endorsed semantic vocabulary matches linked with the LOINC^© assessment questions and answers; and
• HL7^© [Health Level Seven] v2.4 and higher messaging standard and the HL7^© CDA (Clinical Document Architecture (CDA))^m for exchanging standardized federally-required assessment content.³

In conjunction with other federal initiatives, the HITSP, convened by the American National Standards Institute (ANSI) in 2005 under contract to HHS, led efforts to identify and harmonize HIT standards, including those endorsed by the CHI Initiative. Despite the change in presidential administration in 2009, HITSP remained under contract to ONC through January 2010 and continued to play a role in addressing interoperability standards in alignment with the goals of the American Recovery and Reinvestment Act (ARRA) of 2009. ARRA established two new oversight bodies within the ONC, the HIT Policy Committee and the HIT Standards Committee. These committees report to the National Coordinator and are tasked with helping develop HIT data standards and implementation specifications, and with recommending the “meaningful use” criteria for EHR systems to be subsidized by CMS through incentive payments under ARRA.

Post-Acute Care Assessment and Interoperability

Currently, there are three federally-mandated assessment tools used by the CMS for the purpose of compensating and assessing PAC⁴ -- the RAI, including the MDS, used in nursing facilities and swing-bed settings, the IRF-PAI, used in IRFs, and the OASIS, used by HHAs. Each of these instruments is a data collection tool designed to collect information in a format specified by CMS that can be submitted according to CMS’s electronic submission requirements. However, the assessment instruments require information that is not comparable across settings, require different and sometimes proprietary formats for reporting based on care setting, do not use standardized, interoperable HIT vocabularies, do not support standardized health information exchange (e.g., using HL7 messaging standards), and frequently are incapable of interfacing with an individual patient’s EHR.⁵

A 2004 report studying EHRs in LTPAC settings outlined some of the issues that make the collection and subsequent use of this data burdensome:

A final limitation to interoperability that also could be improved by standards development is the integration between the EHR maintained in the various LTPAC sites and the government-mandated data sets: MDS, OASIS, and IRF-PAI. In every case, the information systems for the mandated data set were completely distinct from the EHR. None of the sites was able to import information from the comprehensive clinical assessments contained in the EHR and populate mandated data sets. In most cases, the process for completing the mandated data sets was separate from the process used to maintain the EHR. Thus, the lack of integration between mandated assessments and the clinical information recorded in the EHR was a major impediment to integrated care delivery. Further, the EHR was dominated by orders and assessments written by the physician and/or nurse practitioner, and by nursing and therapy reports of medical care issues such as medications, vital signs, and treatments. However, linkage of mandated data sets and the EHR requires standardized content and messaging not only for the EHR, but also for the federally mandated data sets.⁶

A 2006 report on the viability of a uniform PAC assessment system, prepared for CMS and the Iowa Foundation for Medical Care, explained that the "domains, actual items, item definitions, scoring methods, and metrics differ across tools." Differences in the tools are partially due to the outcomes of care emphasized in a particular setting, so that "even when the domains of health and function are consistent across tools, many of the items used to measure them differ." This study further found that “None of the three existing CMS assessment tools for PAC (MDS, OASIS, IRF-PAI) adequately covers the spectrum of patients and the necessary domains to be used across settings, and mapping across instruments is complex.”⁷

A 2008 study attempting to map between the MDS and IRF-PAI, confirmed the difficulty of evaluating and tracking changes in functional status from one setting to another due to the lack of a single comprehensive assessment instrument for measuring patient outcomes, but noted that attempts to change or replace measures currently in place would face strong resistance from practitioners and administrators who use and rely on these instruments on a daily basis.⁸

In 2009, CMS published in the Federal Register ([74FR10050 (March 9)] and [74FR22208 (May 12]) plans for using revised versions of the OASIS and MDS data sets starting in 2010.⁹ In outlining plans for using a revised OASIS data set for HHAs, CMS stated:

In accordance with long-standing federal objectives, CMS ultimately plans to create a standard patient assessment instrument that can be used across all post-acute care settings. The revision of the OASIS instrument is an opportunity to consider various components of quality care and how patients might be better served as they (and information about them and their care) move among health care settings.¹⁰

In January 2009, anticipating the imminent move to a substantially revised version of MDS, the American Association of Homes and Services for the Aging, in a joint letter with other stakeholders, sent a letter to President-elect Obama’s transition team urging them not to go forward with a proprietary format for reporting MDS 3.0 data.¹¹

In response to the Federal Register notices concerning OASIS and the MDS, a number of organizations reiterated concerns about the continued use of proprietary software for submitting data to CMS.

The National Association for Homecare and Hospice addressed the interoperability issues in comments co-signed by a number of other stakeholder parties:

The implementation of an updated OASIS data set is a unique opportunity to advance interoperability and make a significant impact on home care agencies/EHR products which is the direction healthcare is heading with a goal of widespread, interoperable electronic health records by 2014. The accepted standards exist, but CMS currently does not plan to adopt them for OASIS-C. Instead, CMS plans to continue to collect OASIS-C data using proprietary data exchange formats that are not interoperable -- this is inconsistent with the national agenda to advance EHRs and is short sighted in recognizing the opportunity with the OASIS-C rollout.¹²

AHIMA, in comments to CMS on proposed changes to the Skilled Nursing Facilities Inpatient Prospective Payment Systems published in the May 12, 2009 Federal Register [74FR22208], again addressed concerns about the continued use of proprietary resources for reporting data to CMS:

The proposed rule currently calls for custom transmission of MDS versus the use of HHS accepted standards. By requiring custom transmission of MDS, vendors and providers will be forced to slow their participation in national health information exchange initiatives by diverting resources and focus and develop programs for CMS compliance first, then focusing their efforts on health information exchange.¹³

CMS published the final rules for the skilled nursing facilities (SNFs) PPS [74FR40287, August 11, 2009] and HHAs PPS [74FR58077, November 10, 2009] and confirmed the 2010 implementation dates for MDS 3.0 and OASIS-C. In the final rule for the SNF PPS, CMS responded to stakeholder concerns by saying “CMS appreciates the comments that were submitted with regard to HIT standards and will consider these comments as the MDS 3.0 is implemented.”¹⁴

As CMS continues to improve upon PAC assessment instruments, it is clear that more work needs to be done in standardizing the data and data exchange formats to support continuity of care and interoperability of patient information maintained by the various care facilities.

Prospective Payment Systems for Post-Acute Care

Implementation of a PPS in inpatient acute care facilities in 1983, while exempting most PAC settings,ⁿ contributed to the spiraling costs of PAC, as patients were sometimes moved from one facility to another based on reimbursement policies rather than where they might receive the best care. Because of the PPS, there was impetus to move patients out of acute care facilities at a quicker rate. The growth in federally-funded post-acute health care expenditures led to the Balanced Budget Amendment (BBA) of 1997, which required that PPS be created for nursing homes, rehabilitation hospitals, home health care, and long-term care hospitals (LTCHs).¹⁵ PPS for these PAC settings, three of which are based on setting-specific assessment instruments, were implemented between 1998 and 2002.

Significant legislative activity since the BBA has included the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999,¹⁶ the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000,¹⁷ and the Deficit Reduction Act (DRA) of 2005.¹⁸ Both BIPA and the DRA contained requirements that HHS develop instruments to assess PAC that would be compatible across settings. BIPA required the Secretary of HHS to report to Congress on the "development of instruments to assess the health and functional status of beneficiaries using post-acute care and other specified services…. The assessment instruments required by BIPA are to have readily comparable, statistically compatible, common data elements and include only those elements necessary to meet program objectives.”¹⁹ The BIPA legislation also specified that the standardized instruments developed were to supersede currently-mandated assessment tools:

SEC. 545. DEVELOPMENT OF PATIENT ASSESSMENT INSTRUMENTS.

(a) DEVELOPMENT.--

(1) IN GENERAL.--Not later than January 1, 2005, the Secretary of Health and Human Services shall submit to the Committee on Ways and Means and the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the development of standard instruments for the assessment of the health and functional status of patients, for whom items and services described in subsection (b) are furnished, and include in the report a recommendation on the use of such standard instruments for payment purposes.

(2) DESIGN FOR COMPARISON OF COMMON ELEMENTS.--The Secretary shall design such standard instruments in a manner such that--

(A) elements that are common to the items and services described in subsection (b) may be readily comparable and are statistically compatible;

(B) only elements necessary to meet program objectives are collected; and

(C) the standard instruments supersede any other assessment instrument used before that date.

(3) CONSULTATION.--In developing an assessment instrument under paragraph (1), the Secretary shall consult with the Medicare Payment Advisory Commission, the Agency for Healthcare Research and Quality, and qualified organizations representing providers of services and suppliers under Title XVIII.²⁰

The DRA (Section 5008) charged HHS with developing a single comprehensive assessment to be used upon discharge from inpatient hospitals and in all post-acute sites. A demonstration program was to explore uniform patient assessment and develop payment groups based on severity of illness and resource utilization across post-acute settings.²¹ The Office of Management and Budget (OMB) clearance package supporting the development of the instrument mandated by DRA 2005 claimed: “The lack of a uniform post-acute assessment tool is one of the major limitations to understanding variation in post-acute outcomes, cost-effectiveness, and Medicare payments.”²²

Despite regulatory activity, the three currently mandated assessment tools are not likely to be replaced in the very near term due to the fact that each instrument presently supports setting-specific payment methods, and they are considered by representatives of the individual care settings to be best at supporting clinical care decisions, resource-based reimbursement, and quality improvement initiatives.

Intellectual Property Issues and Mandated Assessment Instruments

The primary intent of this report is to review known IP issues that may affect the ability to use assessment instrument content in an increasingly interoperable environment. Developers or contributors to portions or all of the three PAC assessment instruments under review, the MDS RAI, the OASIS, and the IRF-PAI, claim or have in the past claimed ownership to all or parts of these instruments. Typically, the developers copyrighted the instrument to maintain the quality and integrity of the instrument and the data derived there from, although as these instruments have become integral to reimbursement mechanisms, financial interests may also have played a role. Though likely not with outright intent, instrument developers have employed a two-pronged strategy in encouraging acceptance and then reliance on the instrument, first to promote the use of the instrument as being the most appropriate for the required use, and then to protect the instrument from unauthorized use, either for financial or quality control issues. This continues to hold true with the developers of the MDS/RAI 2.0 and the IRF-PAI.

Although there has been some momentum towards a single comprehensive assessment tool,²³ it is unlikely one will be developed, approved, and implemented in the near term that will completely replace all of the content in the existing instruments. Therefore the need exists to apply HIT standards to the setting-specific assessment data sets currently mandated by CMS. Since third party claims of ownership to all or part of these assessment instruments will likely persist, questions have arisen about the ability and inclination of standards development organizations (SDOs) to link HIT codes to assessment content without first settling the ownership issues and reconciling the IP issues. There are further questions, if HIT codes are linked to legitimately-copyrighted assessment content, as to whether and under what conditions or restrictions the coded assessment content can be disseminated.

It is not clear to what extent simply associating HIT codes with assessment content would constitute an infringing activity under the copyright laws. The copyright owners may argue that the creation of this association in and of itself is a derivative work, which only the copyright owner would have the right to create. In addition, dissemination of HIT coded assessments by a standard setting entity may infringe upon the copyright of an assessment instrument that a third party claims to own, because it could violate the copyright owner’s exclusive right to reproduce, distribute and prepare derivative works based on the assessment instrument.

It also is not clear that claims to exclusive rights to some of the content of these instruments, or the instruments themselves, are always entirely legitimate, as IP issues are frequently complex. However, if non-government ownership of assessment instrument content is established, before undertaking the process of linking HIT codes to assessment content, standard setting entities may need to negotiate agreements and/or licenses with the owners of the assessments to lawfully distribute the HIT codes. Some of these issues have been addressed previously by the NLM in relation to the UMLS. A post on the Integrating the Healthcare Enterprise (IHE) collaborative web site (wiki) asserted that “UMLS is aware of the IP issues and challenges in general, and is exploring ways to address them.”²⁴

It is evident that the creators or developers of all or parts of the MDS/RAI and the IRF-PAI are cognizant of the goal of having an assessment instrument that works across care settings, as both are developing additional, but compatible assessment instruments for use in settings other than that for which their assessment instrument is currently mandated. Carl Granger, representing UDSMR in comments to CMS regarding the adoption of the Continuity Assessment Record and Evaluation (CARE) tool [72FR55225, September 28, 2007], suggests CMS should consider that “using the AlphaFIM^® instrument in acute care settings, the FIM^TM instrument in SNF, IRF, and LTCH settings, and the OmegaFIM^TM instrument (augmented with the LIFEware^SM System) in HHAs would be a more appropriate choice.”²⁵ Brant Fries, president of interRAI, in testimony before the National Commission for Quality in Long-Term Care, promoted the use of the assessment system created by interRAI, covering most of the LTC settings, including “frail elderly in the community, home care, assisted living, nursing homes, post-acute care, (for example, rehabilitation hospitals), palliative care, acute care, and inpatient and community-based mental health; with additional systems underway for intellectual disability and younger persons with disabilities.”²⁶

Intellectual Property Issues and Government Contracts and Grants

Rules concerning rights to works created under government grants or contracts are not black-and-white.²⁷ Competing rights of the contracting agency and the grant or contract recipient need to be weighed. Generally, for work created under contract to or grant by the U.S. government, the award recipient may copyright any work subject to copyright, but the U.S. government reserves the right to use the work for government business, and to authorize others to do so. If the grant or contract recipient is to retain exclusive IP rights, that is most appropriately spelled out in the terms of the contract or grant.²⁸ This does not appear to be the case, at least in the initial stages of development, of the instruments under review in this report. Copyright claimants to all or portions of the MDS/RAI and the IRF-PAI have asserted that their work is copyrightable. They emphasize the award recipient's rights but minimize the broad rights given to the Federal Government.²⁹ Since the Functional Independence Measure was developed as the result of a grant from the U.S. Department of Education, contractors for the IRF-PAI base their copyrights on OMB Circular no. A-110, which allows non-profit organizations that are recipients of grants or cooperative agreements, to copyright content created under the grant or agreement.

The text from OMB Circular no. A-110 reads:

36. Intangible property.

(a) The recipient may copyright any work that is subject to copyright and was developed, or for which ownership was purchased, under an award. The federal awarding agency(ies) reserve a royalty-free, nonexclusive and irrevocable right to reproduce, publish, or otherwise use the work for federal purposes, and to authorize others to do so.

(b) Recipients are subject to applicable regulations governing patents and inventions, including government-wide regulations issued by the Department of Commerce at 37 CFR part 401, "Rights to Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements."

(c) The Federal Government has the right to:

(1) obtain, reproduce, publish or otherwise use the data first produced under an award; and

(2) authorize others to receive, reproduce, publish, or otherwise use such data for federal purposes.³⁰

IP rights to works created under contract with federal government agencies are guided by the data rights sections of the Federal Acquisition Regulations (FARs).³¹ Under the rights in general provisions, unless provided otherwise in the contract, the government has unlimited rights to all data first produced under contract with civilian agencies of the Federal Government. Contractors can claim copyright in published articles, symposia proceedings, or the like, based on or containing content produced under the contract, but ordinarily must obtain permission from the contracting officer before asserting further rights to work produced through the contract. In cases where the contractor asserts rights to works produced under contract, the government customarily includes a contract clause granting the government agency a license to reproduce, prepare derivative works, distribute, perform and display the copyrighted work:

48 CFR §52.227-14 (c) Copyright--

(1) Data first produced in the performance of this contract.

The prior, express written permission of the Contracting Officer is required to establish claim to copyright subsisting in all other data first produced in the performance of this contract. When claim to copyright is made, the Contractor shall affix the applicable copyright notices of 17 U.S.C. 401 or 402 and acknowledgment of government sponsorship (including contract number) to the data when such data are delivered to the government, as well as when the data are published or deposited for registration as a published work in the U.S. Copyright Office. For data other than computer software the Contractor grants to the government, and others acting on its behalf, a paid-up, nonexclusive, irrevocable worldwide license in such copyrighted data to reproduce, prepare derivative works, distribute copies to the public, and perform publicly and display publicly, by or on behalf of the government.

(2) Data not first produced in the performance of this contract. The contractor shall not, without prior written permission of the Contracting Officer, incorporate in data delivered under this contract any data not first produced in the performance of this contract and which contains the copyright notice of 17 U.S.C. 401 or 402, unless the contractor identifies such data and grants to the government, or acquires on its behalf, a license of the same scope as set forth in subparagraph (c)(1) of this clause…

The FAR special works contract clausegives the government the right to control the release and use of data delivered under contract and in all data first produced under contract. The government also has the right to limit the release of the data and can circumscribe the right to establish copyright.³² As with the general rights in data clause, under the special works clause the contractor, with permission from the government, can incorporate previously copyrighted works into the data being delivered if the government gets the same scope of rights that it would get otherwise.

Agreements entered into in the past between the federal agencies and the award recipients who created the data sets upon which the assessment instruments are based, indicate that both the agencies and the developers took a narrow view of what appear to be the government’s rights to the works created under contract or grant, either by mandating how CMS can use the work, or by placing requirements on how and where ownership claims must be displayed. Although not addressing assessment instruments, one analyst wrote concerning copyrights and federally-funded research:

It also appears that the Federal Government does not protect their [sic] reserved rights, much less diligently exercise them on behalf of the public. OMB Circular A-110and its related CFR provisions represent a significant source of latent federal authority that could be used to enhance access to STM [Scientific, Technical and Medical] works.³³

An understanding of the terms of the contracts under which the assessment instruments were developed is vital to determining whether special provisions may have been included in the contracts, statements of work, or other written agreements regarding IP issues. Without access to the language of the contracts, in particular the FAR provisions concerning rights in the data produced through the contracts, it is difficult to determine whether this narrowing of the government's general rights in works created under contract was intentional and written into the contract, approved through written agreement with the contracting officer, or simply asserted beyond the provisions of the contracts.

The push towards interoperable health information systems may give rise to additional IP issues. In December 2007, the Department of HHS informed the public by means of a Federal Register notice of the adoption of the CHI Patient Assessment standards (as well as standards for Multimedia and Allergy) and announced that the “Federal Government will require all future federal health information acquisitions to be based on CHI standards…”.³⁴ As CMS moves towards implementing new assessment instruments (e.g., the CARE instrument) it does so with the recognition that new assessments will have to be implemented using the HIT requirements for exchanging and reusing standardized federally required patient/client assessments. CMS included a requirement that the instrument comply with CHI standards in its contract to develop the CARE instrument.³⁵ Applying CHI standards to federally required patient assessments will support interoperability of health information if this standardized information can be exchanged and re-used across settings. However, as previously noted, IP claims often constrain the ability to freely disseminate standardized patient assessment content.

The following pages will outline the history and development of the three PAC assessment instruments currently mandated by CMS for reimbursement purposes, and will describe known IP issues. The summaries will address what the instruments are and what they are used for. Regulatory background concerning how and why the instruments were created and mandated for use will be reviewed, as well as how and by whom the instruments came to be created, and how and by whom the instruments have since been developed. Where known, the report will cover how IP issues that have previously arisen have been addressed. Understanding how federally-required patient assessments were developed in the past and the resultant IP claims may provide policy makers and others with information to support the development and standardization of patient assessment instruments for free and widespread use in an increasingly interoperable healthcare environment.

Resident Assessment Instrument/Minimum Data Set

The RAI, which includes the MDS, is a standardized data collection instrument designed to assess and screen care given to residents in nursing facilities. The RAI is mandated for all residents in Medicare or Medicaid-certified nursing facilities in the United States. The assessment items that make up the core MDS are considered the minimum elements required to provide a comprehensive picture of a resident’s functional status.³⁶ The MDS was designed to standardize assessment data nursing homes were collecting already as part of their routine business.³⁷ While the primary use of data collected through the MDS was to direct and improve clinical care, the MDS has also become the basis for setting payment levels and monitoring quality of care, in addition to directing certain state survey and certification activities for nursing homes.³⁸

Full MDS data must be collected on all nursing home residents within fourteen days of admission and either annually thereafter, or when there is a significant change in condition. Data from the MDS are used to trigger specialized Resident Assessment Protocols (RAPs), through which individual care plans for at-risk patients are developed. A subset of MDS data must be collected on a quarterly basis to assess how well the care plan is working. The MDS, RAPs, and utilization guidelines, instructions on when and how to use the RAI, are the three core components of the RAI. In version 3.0 of the RAI, scheduled for implementation in October 2010, the Care Area Assessment (CAA) process replaces the RAPs.

MDS assessments must be encoded and electronically transmitted from the care facility to the CMS contractor in the state government. This data is then forwarded to CMS. In the FY 2010 proposed rule for SNF PPS published May 12, 2009 [74FR222208], CMS proposed that LTC facilities be required to transmit MDS data directly to the national CMS System, instead of to the states. The transmission file of MDS data must meet the data specification standards set by CMS. CMS makes available free software (RAVEN) that Medicare and Medicaid nursing facilities may use to electronically transmit MDS assessments.³⁹

Regulatory Background (40)

The Omnibus Budget Reconciliation Act (OBRA) of 1987 included a sweeping set of regulatory reforms for nursing homes. Even prior to, but particularly when Medicare began reimbursing for post-acute nursing home care and Medicaid began paying for long-term nursing home care, there were complaints about the quality of care. These complaints led to a class action lawsuit filed in the late 1970s against the HCFA to ensure nursing homes met regulatory standards.⁴¹ In 1983, Congress directed HCFA to study how to improve nursing home regulation. HCFA contracted with the Institute of Medicine (IOM) of the National Academy of Sciences to investigate the quality of care in nursing homes, and to study and recommend changes to existing regulations to ensure quality care. Concurrently, HCFA funded a number of demonstration projects to assess regulatory alternatives for improving the quality of care.⁴²

Prior to OBRA of 1987, the Conditions of Participation for nursing homes were based on the facility’s potential to provide care more than the actual quality of care provided.⁴³ One of the major findings in the IOM study published in 1986 was that a uniform comprehensive assessment of each nursing home resident was essential to improving the quality of care. OBRA of 1987 incorporated many of the recommendations in the IOM report, including amending the Social Security Act to require that the Secretary of HHS specify a minimum data set for use in conducting comprehensive assessments and to designate one or more resident assessment instruments based on the minimum data set. Regulations mandating the completion of the RAI for every nursing home resident went into affect on October 1, 1990, although implementation was postponed until the spring of 1991.⁴⁴ A revised RAI/MDS 2.0 was implemented across all nursing homes in 1996, and a significantly revised MDS 3.0 is scheduled to be implemented nationally on October 1, 2010.⁴⁵

In addition to the quality issues addressed by OBRA of 1987, spiraling costs of federally-funded PAC, partially attributable to the implementation of a PPS for acute care in 1983 while exempting PAC facilities, were addressed in the BBA of 1997, which dictated cuts in Medicare spending growth and changes in the way PAC was reimbursed.⁴⁶ The PPS for nursing facilities, using Resource Utilization Groups (RUGs) based on data collected in the MDS, went into affect in July 1998. In some states Medicaid payments also are based on MDS data. Electronic submission of MDS data to a national repository housed at CMS to facilitate payment and quality evaluation was made mandatory in July 1998.⁴⁷

Creation and Development of the Minimum Data Set

Based on recommendations in the 1986 IOM study, in 1988 the HCFA's Health Standards and Quality Bureau contracted with a project team led by the Research Triangle Institute (RTI), with subcontractors from the Social Gerontological Research Center, HRCA (Boston), the Center for Gerontology and Health Care Research, Brown University (Providence, Rhode Island), and the Institute of Gerontology, University of Michigan (Ann Arbor) to develop and evaluate a national assessment instrument and data system for nursing home assessment in the United States.⁴⁸ The Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and the RAPs, which are triggered by MDS assessment items or combinations of items, were developed through this contract. An expert panel representing a wide variety of clinical disciplines and professional organizations involved in geriatrics served in an advisory role. From 1989 to 1991, these experts participated at every stage of the design and testing of the MDS.⁴⁹

Version 2.0 of the RAI/MDS was developed under a second contract awarded by HCFA in 1994 to the HRCA, a subcontractor on the original contract.⁵⁰ The 1995 training manual for version 2.0 was written by HRCA in conjunction with HCFA. The 2002 and 2007 updates to the manual appear to have been written by CMS (HCFA’s successor agency) staff. The interRAI web site states that members of interRAI developed the RAI and the RAPs for the MDS version 2.0, and calls the RAI "The interRAI LTCF".⁵¹ InterRAI refers to the RAPs as Clinical Assessment Protocols (CAPs), "in recognition of their applicability to more populations than nursing home residents alone."⁵² While it is undoubtedly true that those who were major contributors to MDS 2.0 are or were also members of the interRAI, a 2001 letter to the editor of The Gerontologist from an employee at HCFA made it clear that in terms of the contract for developing MDS 2.0, there was no direct relationship between HCFA and interRAI.⁵³

The MDS 3.0 revision appears to have originated within the Office of Clinical Standards and Quality at CMS and revised based on comments received from the nursing home industry, professional groups, individual providers and expert panels. To initiate the revision, CMS worked with stakeholders in identifying objectives, chief of which was to improve clinical relevance.⁵⁴ CMS’ goal with respect to the revision was to reduce provider burden and improve clinical items such that data collected would be clinically relevant, accurate, and useful. CMS also sought to limit the data submitted to information the Federal Government needed to know, such as issues surrounding payment, quality, and regulatory oversight.⁵⁵ The data collection form was restructured for greater usability, and items that were confusing or unnecessary were deleted. Another goal of MDS 3.0 was improving user satisfaction and increasing the efficiency of collecting data for reporting purposes. Long-term goals include moving toward standardized nomenclature and integration of the assessment into EHRs.⁵⁶

A draft MDS 3.0 was released in April 2003 for public comment. At the same time, CMS awarded a contract to the RAND Corporation to evaluate the revision, including validating new and revised sections of the draft in community populations and facilities. Areas of emphasis in the revision include diagnostic coding, delirium, pain, falls, depression, behavior disorders, quality of life, and palliative care. Key changes include basing assessments, when possible, on resident interview, and also a focus on improving accuracy and efficiency.⁵⁷ The Commonwealth Fund provided RAND with grant money to convene a panel of nursing home experts to provide input.⁵⁸

The evaluation team, in addition to RAND, included the Harvard Medical School Department of Health Care Policy, the Colorado Foundation for Medical Care (a Quality Improvement Organization), Carelink (for developing the Instructions and Guides), the Kleinmann Group, and RSS Consulting Services.⁵⁹ In December 2003, the scope of the project was expanded when CMS signed a Memorandum of Understanding (MOU) with the Veterans Health Administration (VHA) to work together to improve the MDS 3.0. In October 2004, VHA Health Services Research and Development (VHA HSR&D) initiated a large research project to validate changes in MDS 3.0 in VA nursing homes, in order to contribute to the 3.0 revision.⁶⁰

As part of the RAND study, a workgroup was assembled to review the instruction manual developed for MDS 3.0. This workgroup included representatives from the RAI Coordinator Group, the American Association of Nurse Assessment Coordinators, the American Health Care Association, the American Association of Homes & Services for the Aging, and the VHA. The RAND contract for evaluating MDS 3.0 ended March 31, 2008, and the report was released in April 2008.⁶¹

Initially, MDS 3.0 appeared to be on a fast track, with a revision expected to be available by December 2004.⁶² However, a coalition of stakeholder organizations in LTC submitted a letter of concerns, including the need for development of MDS 3.0 to be coordinated with activities promoting HIT and HIT standards.⁶³ In August 2004, HHS's ASPE and CMS co-funded a project through which Apelon Systems, a medical terminology and vocabulary contractor, would attempt to apply HIT standards to a sample of the MDS to demonstrate how standardization would support the use of content and messaging standards and assure that patient data be interoperable and comparable across settings.⁶⁴ As noted above, these HIT content and messaging standards were approved by the Secretary of HHS as accepted CHI standards and announced in a Federal Register notice in 2007.⁶⁵ In 2007, the AHIMA Foundation, with subcontractors from Regenstrief (LOINC), Apelon Systems, and Altshuler Associates (HL7), began work on a contract with ASPE to apply content and exchange standards to the full MDS, starting with the MDS 2.0 data set and moving to MDS 3.0 when CMS made clear their intent to implement the revised assessment tool and data set.

Based partially on concerns voiced by a number of stakeholders regarding how data submitted to CMS under the MDS 3.0 would work with electronic records and the limited time available to implement system updates and provide staff training from the time when materials would be ready to the proposed implementation date, CMS extended the original implementation date from October 2009 to October 2010. The American Association of Homes and Services for the Aging wrote a letter to President-elect Obama's transition team encouraging the delay in order to make the MDS 3.0 interoperable, arguing that CMS could achieve interoperability under the MDS by adopting certain standards instead of CMS’ proprietary data exchange formats.⁶⁶ Others voiced similar concerns after the proposed rule for implementing MDS 3.0 was published in May 2009.

In the FY 2010 proposed rule for skilled nursing facility (SNF) PPS [74FR222208], CMS acknowledged the concerns about interoperability issues, and announced they would implement MDS 3.0 using the LOINC representation of the MDS 3.0 data set. CMS considered use of the HL7 Clinical Document Architecture (CDA) for exchanging standardized assessment content, but did not feel comfortable with its adoption without further study to gauge the impact of its use on such a large scale process as the submission of MDS data, which numbers approximately 30 million submissions annually. Similarly, CMS studied the use of the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), but did not feel the semantic matching to MDS data was sufficient for CMS' payment, survey, and quality measurement needs. CMS indicates they have no plans to include the HL7 Clinical Document Architecture (CDA), messaging standards, or SNOMED-CT in the October 2010 release of MDS 3.0. CMS is considering the use of HL7 messaging standards with the CARE tool, but stated, “We are soliciting comments on the most appropriate clinical standards to use for clinical assessment instruments.”⁶⁷ In the final 2010 SNF PPS rule [74FR40288], the issue of interoperability standards was not addressed.

The final version of the MDS 3.0 item set, data specifications and resident assessment manual, also was delayed to provide time to work on pieces such as the care area assessments, which replace the RAPs, the RAI user’s manual, quality measurements, and CMS’ Five Star Quality Rating System for nursing homes. Portions of The Long-Term Care Facility Resident Assessment Instrument User’s Manual for Version 3.0 were released in November 2009 and the complete manual was expected to be available sometime in early 2010. Copyright information contained in the RAI manual indicate it is a public document and may be copied freely. The manual recognizes a number of organizations and stakeholders, LTC experts, contractors, and CMS staff for their contributions to the “development, testing, writing, formatting, and review of the MDS 3.0 RAI Manual, MDS 3.0 Data Item Set, and MDS 3.0 Data Specifications.”⁶⁸ The RUG Version IV (RUG-IV), a new classification system designed for use with MDS 3.0, was developed through the CMS-sponsored STRIVE (Staff Time and Resource Intensity Verification) project carried out by the Iowa Foundation for Medical Care of West Des Moines, Iowa.⁶⁹

The development of MDS 3.0, though separate from, is linked to the development of a new assessment tool, the CARE instrument, and MDS expertise has been shared with the developers of CARE. The principal investigator on the MDS 3.0 project is also an advisor to the CARE demonstration project.⁷⁰ CMS is developing a roadmap to address the future, and a strategic vision for the assessment instruments, including CARE and MDS. Despite the delays, MDS 3.0 is now on schedule for implementation in October 2010, while a report to Congress with the results from the CARE demonstration is required in 2011.⁷¹

Intellectual Property Issues

The copyright notice for RAI/MDS 2.0 on the CMS web site states: “Please note that InterRAI [sic] holds the copyright to Version 2.0 of the RAI for long-term care outside of the US. Therefore, this revised Version 2.0 of the RAI/MDS manual should not be reproduced outside of the United States without permission of InterRAI [sic]. Within the US, Version 2.0 is in the public domain.”⁷²

The RAI/MDS Version 2.0, currently in use, and related training materials were developed by the HRCA under a contract with HCFA. Lead authors on the 1995 edition of the User's Manual for Version 2.0 were John N. Morris and Katharine Murphy from HRCA and Sue Nonemaker from HCFA.⁷³ The 2002 and 2007 revisions to the User's Manual for Version 2.0 appear to have originated within CMS. A number of individuals are acknowledged, many of whom appear to have been members of the MDS Coordinating Team within CMS.⁷⁴

IP issues with respect to the RAI/MDS are complicated because the assessment instrument and data set have always been considered to be in the public domain, but only in the United States. Beyond United States borders, interRAI claims rights to version 2.0 of the RAI and MDS, and use of the RAI/MDS requires a license agreement with interRAI. IP issues are futher complicated by the fact that the 1995 edition of the user's manual for version 2.0, written for and with HCFA, has been copyrighted by interRAI with the U.S. Copyright Office, which is unusual for a work considered to be in the public domain.

InterRAI is an international consortium of researchers in the area of LTC systems, formed in 1992, whose aim is to use MDS data to study LTC in individual countries and to enable cross-national comparisons.⁷⁵ Brant Fries, a founding member of interRAI and an investigator for the HCFA contracts, described interRAI in testimony before the National Commission for Quality Long-Term Care in 2005:

Let me say a few words about interRAI, and then about what it has developed. interRAI is a cross-national collaboration of 47 expert clinicians, researchers and policy-makers from 26 nations spanning the globe. We develop assessment systems that can accomplish the tasks I have been describing. As a non-profit corporation that holds the copyrights, interRAI gives its assessment systems for free to any government or caregiving organization around the world.⁷⁶

The interRAI web site indicates that use is granted freely to government agencies worldwide. However, issues concerning use of the MDS outside of the United States, including barriers, were addressed in a 2003 Milbank Memorial Fund report, entitled Implementing The Resident Assessment Instrument: Case Studies Of Policymaking For Long-Term Care In Eight Countries. This report made it clear that "free" did not necessarily mean unhindered. Regarding Ontario, Canada, the report indicated there were a variety of factors that made introducing MDS 2.0 a challenge, including the fact that there was not a “pre-existing working relationship with interRAI, the international research group that developed and owns the rights to the MDS." Also, the government had mandated that data be submitted electronically, “but interRAIhad not licensed any software vendors to sell MDS software in Canada." About Japan, it was written: "The fact that the MDS items were protected by copyright presented another hurdle to the adoption of an MDS-based instrument. The government would have had to negotiate with interRAI if any changes had been necessary, which the government was unwilling to do." The Japan report goes on to say: "If MDS items had been used in the assessment form, they would have been embedded in the LTCI [long-term care insurance] and integrated with care planning. This might have been possible if interRAI had adopted a more flexible attitude toward the copyright issue, because the government’s concern lay in maintaining a free hand in negotiation rather than actually making substantive revisions." In Spain, Spanish translations were completed, software was created to support the data collection needs, and “the software company formalized a contract with interRAI to produce and distribute RAI-NH software commercially." In Italy, the pharmaceutical company Pfizer obtained an interRAI license for the RAI for home care, and financed its “translation, computerization, and implementation.”⁷⁷

Fairly extensive copyright and licensing information for use of the set of RAI instruments is provided on the interRAI web site.⁷⁸ InterRAI claims copyright to version 2.0 of the RAI/MDS outside of the United States, and a set of additional assessment instruments, presumably both within and outside United States borders. The interRAI web site lists these major clauses as part of their royalty-free license agreements:

• the instrument is not to be changed substantially (excepting individual identifiers and demographics);
• the license is limited to non-commercial use (i.e., the instrument will not be incorporated into products to be sold to others);
• no royalties will be charged;
• the organization will make appropriate efforts to inform others of the copyright status of the instrument;
• interRAI's logo and copyright notice are to appear on the form;
• authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual);
• publication of any training manual is limited to the period until a commercially-published version is available;
• data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality.⁷⁹

Licensing for commercial use generally requires that royalties be paid to interRAI. All of the clauses that apply to royalty-free licenses apply to licenses for commercial use as well, although interRAI indicates they may omit the requirement that data collected using the instrument be shared with interRAI.

InterRAI’s policies concerning collaboration and instrument development include willingness in “contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation.”⁸⁰ InterRAI and the Ontario Joint Policy and Planning Committee, a partnership of the Ontario Ministry of Health and Long Term Care and the Ontario Hospital Association, collaborated, beginning in 1996, on a RAI for mental health (RAI-MH). A research team based in Ontario led the effort. Those two organizations share copyright ownership with interRAI for that particular instrument, and use without additional license agreement in Canada is allowed. The copyright notice for that instrument reads: “The RAI-MH is a copyrighted instrument that is owned jointly by the Ontario Ministry of Health, the Ontario Hospital Association, and interRAI.”⁸¹

The other instruments in the suite of data collection tools for assessing across the continuum of care, for example home care, assisted living, palliative care, and acute care, appear to be solely the IP of interRAI, and their use subject to licensing agreements with interRAI. InterRAI has promoted the complete set of assessment instruments as suitable for assessing all PAC patients.⁸²

Since publication of the Milbank report, Canada, or at least the province of Ontario, appears to have developed a close working relationship with interRAI. A number of assessments from the interRAI suite are used in Canada, and three have been adopted by the Canadian Institute for Health Information (CIHI) as national standards,⁸³ with interRAI retaining ownership rights. On the CIHI web site, interRAI’s ownership of MDS 2.0 is prominently displayed. Manuals for RAI MDS 2.0 and RAPs Canadian Version: User’s Manual are available electronically for free downloading from the web site for LTC facilities, but must be ordered.⁸⁴ Samples of other copyright notices from English-speaking countries using the RAI are available on the interRAI web sites from the United Kingdom^o, Australia^p, and Hong Kong^q.⁸⁵

IP issues with respect to the MDS are known to the NLM and the Regenstrief Institute, the owner of Clinical LOINC, an HL7-approved coding system for observation identifiers and a CHI-endorsed standard for federally-required assessment forms.⁸⁶ The NLM and Regenstrief have negotiated with, presumably, interRAI, to incorporate MDS 2.0 into LOINC and the UMLS. Contact information for MDS 2.0 in the UMLS does not mention interRAI, but instead names Brant Fries at the Institute of Gerontology of the University of Michigan, who is also president of the interRAI consortium.

The designation for the MDS in the UMLS is LNC_MDS20 -- Minimum Set 2.0, Institute of Gerontology, University of Michigan, 300 North Ingalls, Ann Arbor, Michigan 48109-2007 USA. Use of the MDS 2.0 through the UMLS is subject to category 3 (for non-United States users) and category 4 (for United States users) restrictions, as outlined below:

Category 3:

LICENSEE's right to use material from the source vocabulary is restricted to internal use at the LICENSEE's site(s) for research, product development, and statistical analysis only. Internal use includes use by employees, faculty, and students of a single institution at multiple sites. Notwithstanding the foregoing, use by students is limited to doing research under the direct supervision of faculty. Internal research, product development, and statistical analysis use expressly excludes: use of material from these copyrighted sources in routine patient data creation; incorporation of material from these copyrighted sources in any publicly accessible computer-based information system or public electronic bulletin board including the Internet; publishing or translating or creating derivative works from material from these copyrighted sources; selling, leasing, licensing, or otherwise making available material from these copyrighted works to any unauthorized party; and copying for any purpose except for back up or archival purposes.

LICENSEE may be required to display special copyright, patent and/or trademark notices before displaying content from the vocabulary source. Applicable notices are included in the list of UMLS Metathesaurus Vocabulary sources, that is part of this Agreement.

Category 4:

LICENSEE is prohibited from translating the vocabulary source into another language or from altering the vocabulary source content. 12.4.2. LICENSEE's right to use the vocabulary source is restricted to use in the United States by LICENSEE's employees, contractors, faculty, students, clients, patients, or constituents within electronic systems or devices built, purchased, licensed, or used by LICENSEE for United States governmental purposes or for any health care, public health, research, educational, or statistical use in the United States. Use by students is limited to research or educational activities under the direct supervision of faculty. 12.4.3. LICENSEE has the right to distribute the vocabulary source in the United States, but only in combination with other UMLS Metathesaurus content. Further, LICENSEE's right to distribute is restricted to: 1. Electronic distribution to LICENSEE's direct United States affiliates, or to other United States entities that have signed the UMLS license, in order to facilitate use of the vocabulary for health care, public health, research, educational or statistical purposes in the United States only. 1. LICENSEE must take reasonable precautions to prevent distribution of the vocabulary source to non-US entities. 2. LICENSEE must include in its annual report a list of all United States affiliates or other United States entities to whom it has distributed content from the vocabulary source. 2. Distribution of encoded patient level data sets or knowledge encoded in the vocabulary source by LICENSEE to any United States entity for use in the United States only. 3. Inclusion of encoded records or content from the vocabulary source in: (1) free publicly accessible retrieval systems or (2) fee-based retrieval systems that are accessible within the United States only, provided that these systems do not permit users to copy or extract any significant portion of the vocabulary source. 12.4.4. DEFINITIONS 1. United States is defined as all United States states, territories, and the District of Columbia; any United States government facility or office, whether permanent or temporary, wherever located; and access to a system in any of these locations by United States government employees, designated representatives or contractors, wherever located, for United States government purposes. 2. United States entity is defined as (i) for government entities, an agency or department of the United States government, (ii) for corporations, as a corporation incorporated and operating in the United States and (iii) for other entities as an entity organized under the laws of the United States.⁸⁷

The LOINC database is a public-use set of codes accessible in the United States and internationally. MDS information in LOINC, including supplemental material added to LOINC representations, cannot be reproduced without interRAI permission outside of the United States.

Generic agreement text on the LOINC web site reads:

third party content is either used with permission or under the applicable terms of use. In all such cases, we have included the copyright notice. This third party content is highlighted in the program as follows: When such copyright content appears in the RELMA [Regenstrief LOINC mapping assistant] look-up grid, RELMA will highlight the row containing that content by printing in a different background color and using italics. It will also include a link in the (EXT (C)) column. By clicking on that link, users will get to the copyright notice and to the terms of use for the content of those LOINC-mapped terms. In the case of a LOINC database (e.g., the tab delimited file and the LOINC Access database) we include the copyright notice (up to 250 characters).⁸⁸

RELMA provides the following language concerning the interRAI MDS copyright claim:

As a not for profit corporation under the U.S. Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long-term care facilities outside of the United States (the RAI is in the public domain within the United States), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care.⁸⁹

An IP issue that may have been addressed although, if so, it is not clear how it was resolved, regards the creation of scales based on the MDS. Copyright information on the interRAI web site includes the statement: "The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted).”⁹⁰ Presumably, this refers to scales created by interRAI, since LTCQ, Inc. claims ownership rights to the Cognitive Performance Scale (CPS), a well-known scale based on the MDS. It is unclear whether claiming copyright to the MDS-based CPS is in direct conflict with the terms on the interRAI web site. LTCQ, a consulting company formed in 1992 by other participants in the HCFA MDS contracts, has patented or trademarked Data Integrity Audit, Performance Portfolio, RiskRx, and Q-Metrics. In addition to the CPS, LTCQ claims copyrights to the Pain Scale (PS), Pressure Ulcer RAP Items [scale], Pressure Ulcer Risk Model [scale], Depression Rating Scale (DRS), and the Social Engagement Scale, all of which are based on v.2.0 MDS data.⁹¹

A large number of organizations, government agencies, contractors, and industry experts have been involved in the creation and development of the third revision of the MDS item set along with associated pieces such as the data specifications, resident assessment instrument and user manual, care area assessments, and RUGs classification. At this point, there do not appear to be restrictions on the use of any of the parts of the version of the RAI scheduled for implementation in 2010. MDS 3.0 incorporates screening tools for depression (PHQ-9^©) and delirium (CAM^©), that are copyrighted, but presumably fall under the rights in general provisions of the FARs which states that a Contractor may not, without permission of the Contracting Officer, incorporate any copyrighted material unless the Contractor grants to the Government, or acquires on its behalf, a license to use the material. The CMS indicates copyright permission for the PHQ-9^© and the CAM extends to any use of the instrument made in connection with reporting to CMS, as long as the copyright symbol is present.⁹² The CARE tool displays the statement, "Copyright^©1990 Annals of Internal Medicine. All rights reserved. Adapted with permission."

Use not associated with reporting to CMS and any replication of the CAM requires this acknowledgement:

Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Sharon K. Inouye, M.D., MPH.⁹³

Information concerning the CAM^© in the Agency for Healthcare Research and Quality's (AHRQ) National Quality Measures Clearinghouse is contradictory. According to the copyright statement on the NQMC web site, no copyright restrictions apply,⁹⁴ but the measure availability statement states: "Please note that the CAM is copyright protected, therefore you must apply for permission to replicate the CAM within your facility."

While it is not know what restrictions might be placed on the use of these tools by third parties in the future, the Regenstrief Institute has made arrangements with Pfizer in the past to resolve IP issues in relation to incorporation of the PHQ tools into LOINC and has also received permission from the copyright holder of the CAM to include that tool in the worldwide LOINC distribution.⁹⁵

Outcome And Assessment Information Set (OASIS)

The OASIS is a data collection instrument designed to measure adult, non-maternity patient outcomes in the home health care setting. The data elements "represent core items of a comprehensive assessment for an adult home care patient; and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)."⁹⁶ While the primary objectives of creating the OASIS were to support both systematic collection of data and quality improvement initiatives to benefit HHAs and their patients, secondary objectives were to meet the needs of payers, regulators, and the government.

OASIS data must be collected on all home health patients at the initial visit and at certain other episodic and periodic time points, including time of discharge.⁹⁷ The complete OASIS assessments must be electronically transmitted within 30 days of assessment completion date to the state health agency (or Medicare contractor) for storage in an electronic database, and are then forwarded to the CMS.

CMS makes available free software (HAVEN) which Medicare and Medicaid HHAs may use to electronically transmit MDS assessments.⁹⁸

CMS expects to continue to collect data using OASIS for the foreseeable future, but indicates that priorities like pay for performance, standardizing assessment and quality measurement, integration of measures of process and systems, and EHRs may impact future use of OASIS.⁹⁹

Regulatory Background (100)

Since mid-1999, the CMS and its predecessor agency, the HCFA have required all certified HHAs to systematically use the OASIS to measure functional status and medical conditions of Medicare beneficiaries receiving home health care and to send assessment data to a central repository. The Conditions of Participation for Home Health Agencies were revised in 1999 to reflect the regulation first published in the Federal Register (64 FR 3764) that stated each patient must receive from the HHA a "patient-specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient's continuing need for home care and meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs." (CFR 42 §484.55). The Conditions of Participation also require that the comprehensive assessment "incorporate the use of the current version of the OASIS items, using the language and groupings of the OASIS items, as specified by the Secretary." (CFR 42 §484.55).

A second rule, published concurrently with the initial regulations requiring the use of OASIS, provided guidelines for the electronic transmission of the OASIS data set, set out the responsibilities of the state agency or HCFA Medicare contractor in collecting and transmitting the information to HCFA, and set forth rules concerning the privacy of patient identifiable data generated by OASIS, all of which were required in order to create a PPS for HHAs.

Since October 2000, OASIS data has served as the basis for the PPS for reimbursing home health services. Since 2003, data collected through the OASIS instrument have been used by CMS to support home health care quality initiatives. OASIS data are also used by CMS to assess compliance with the Pay for Reporting requirements of the DRA of 2005. CMS views the use of the same data to support both quality monitoring and payment as their way of ensuring HHAs are not maximizing reimbursement at the expense of quality outcomes. In March 2009, CMS published a request for comments in the Federal Register regarding the use of a revised OASIS, and in July 2009 received the OMB approval to use OASIS-C. In August 2009 CMS published the final rule which established January 1, 2010 as the required date for HHAs to begin using OASIS-C.

Creation and Development of OASIS

In the late 1980s, the HCFA, along with the Robert Wood Johnson Foundation and later the New York State Department of Health, provided funding to the Center for Health Services and Policy Research at the University of Colorado to assess the feasibility and usefulness of measuring the outcomes of home health care.

The OASIS data set, which allowed HHAs who were already collecting assessment data to do so in a more precise form, was developed over a period of years. The original 73-item data set was first published in a report by the Research Center in 1994. The data set has gone through several iterations of expanding and refining since then, as it was anticipated at the time of initial implementation that OASIS would evolve to reflect changes in quality measurement, health research, health policy, reimbursement, and standards of care. Shortly after the data set was first published, a task force of home care experts convened by HCFA reviewed the items and recommended additional items considered essential for patient assessment. In 1995, incorporating input from the task force, the Research Center revised and rearranged the items into a data set that was called OASIS-A. This data set was used and tested in two demonstration programs in 1995 and 1996. The demonstration programs suggested select refinements which resulted in OASIS-B. Subsequently, OASIS-B was modified slightly to take into account HCFA's needs for data management and administration. The version containing these modifications was released in 1998 and was referred to as OASIS B-1. Further revisions were made to OASIS B-1 in 2007 to support the revised PPS effective January 1, 2008.

As of December 31, 2005, the Colorado Outcome Reporting and Enhancement (CORE) Research Partnership, which appears to have been an extension of the Research Center's (now the Center for Health Services Research) work with OASIS, ceased operations.¹⁰¹

Development of modifications to the OASIS-B1 instrument began in 2005 following input from a variety of stakeholders that included industry feedback, recommendations from the National Quality Forum (NQF), and an expert panel who identified best practice process measures. In September 2006, CMS contracted with Abt Associates and subcontractors from the University of Colorado Health Sciences Center and Case Western University to help CMS refine the OASIS data set.¹⁰² Earlier recommendations, along with a major effort to align OASIS measures with those of other assessment instruments, including the Minimum Data Set (MDS) and the Continuity of Care Record Evalution (CARE) tool, formed the basis of the OASIS revisions. CMS viewed the revision as an opportunity to address quality of care across the health care continuum as patients moved among health care settings.

OASIS-C testing was completed in 2008 and a revised instrument revision posted in November 2008. After a comment period that ended in January 2009, a revised final version was submitted to the OMB in compliance with the Paperwork Reduction Act, and after receiving OMB approval, posted to the CMS web site August 12, 2009.¹⁰³

Intellectual Property Issues

Prior to 2008, rights to the OASIS instrument were retained by the Center for Health Services and Policy Research in Denver, Colorado. The Research Center, however, granted the right to use the OASIS tool freely, as evidenced by the copyright notice on the CMS web site,¹⁰⁴ and previous agreements that were reached with the NLM¹⁰⁵ and LOINC.¹⁰⁶

The OASIS implementation manual was originally developed in 1999 and has been revised several times to reflect changes to the OASIS data set. A revised manual was released in September 2009 as part of the project to upgrade the instrument to OASIS-C.

The designation for the OASIS in the UMLS is LNC221_OASIS_2002 -- the OASIS. The owner of the data set is the University of Colorado Center for Health Services Research (UCHSC) in Denver, Colorado. Contact information for the OASIS is Andrew Kramer, MD at UCHSC. Use of the OASIS through the UMLS is subject to category 3restrictions, referenced in the section on the MDS, above.

The OASIS is also represented in the LOINC database. The text of the agreement concerning third party content in the LOINC database is referenced in the section on the MDS, above.

RELMA provides the following language concerning the OASIS copyright claim:

RIGHT TO COPY, REPRINT, AND USE OASIS.

The Outcome and ASsessment Information Set (OASIS) is the intellectual property of the Center for Health Services Research, Denver, Colorado, and may not be copyrighted by any other party. It is our intent to permit the free use of OASIS by home care providers and related organizations, businesses, and individuals, to be incorporated into patient or client assessment forms or software. To this end we grant all such organizations or individuals the nonexclusive right to copy or reprint the contents of the OASIS and to incorporate OASIS items into printed forms, software, or other products. No royalty or use fee is required, but acknowledgement of authorship is expected.¹⁰⁷

As of late 2007, Copyright information on the CMS OASIS web site indicated that OASIS B-1 was now in the public domain. Copyright information on the CMS web site reads: "The Outcome and ASsessment Data Set (OASIS) B1 (1/2008) is in the public domain and may not be copyrighted. No permission is needed to copy and use the data set." Similar text is in the OASIS Implementation Manual: Appendix B, dated January 2008.¹⁰⁸ There is no information with regard to copyright and OASIS-C on the CMS web site, and the issue is not addressed in the OASIS-C guidance manual.

CMS requires that state health agencies transmit encoded OASIS data in a format conforming to the CMS standard electronic record layouts, edit specifications, and data dictionary. The HAVEN system, developed by CMS, supports the data transmission requirements, but other software programs conforming to CMS requirements have also incorporated OASIS into their programs for the purpose of transmitting the data to CMS. There is no indication IP issues were ever a barrier.

Samples of paper assessment forms sold by the Briggs Medical Services Company over the years claim copyright to the forms, but also note that the OASIS data set is the IP of the Center for Health Services and Policy Research, and was being used with permission.¹⁰⁹

Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI)

The IRF-PAI is a data collection instrument used to document the effectiveness and efficiency of rehabilitation care. It is used in IRFs and in distinct rehabilitation units of acute care facilities. IRF-PAI was developed for the CMS and is based in large part on the Functional Independence Measure (FIM), a tool comprised of eighteen assessment items related to motor activities and cognitive skills, each item being accompanied by a rating scale of one to seven, designating level of dependence.¹¹⁰ The sum of item scores describes severity of disability and reflects how much assistance is required to complete activities of daily living (ADLs). As severity of disability changes during rehabilitation, FIM^® data can be used to track changes and analyze outcomes of treatment. The FIM^® tool, by design, includes a minimum number of items. It was originally created to support research and to improve the quality of care in rehabilitation facilities. However, as described in more detail below, in 1995, HCFA entered into a licensing agreement that gave HCFA permission to use the FIM in the IRF-PAI, and for classifying patients into case-mix groups for reimbursing IRFs for Medicare Part A-covered services. Since the scale rates patients according to their need for assistance to perform a particular activity, the need for assistance translates to the time and energy another individual must spend to serve the needs of the functionally-impaired individual.

Admission FIM^® scores must be collected during the first three calendar days after admission to an IRF. Scores are based on activities performed during the entire three-day period. The discharge assessment includes activities performed on the day of discharge and two days preceding.

Both admission and discharge IRF-PAI items must be completed before data records are transmitted to the CMS.¹¹¹ Completion of all items in the IRF-PAI, except the sections for Medical Needs and Quality Indicators, is mandatory. For reimbursement, federal regulations require that patient data be collected within the facility and submitted electronically using the free software (IRVEN^r) available from the CMS web site. The data collected by CMS are used also to develop an analytical database for monitoring and assessing the implementation of the payment system.

Regulatory Background (112)

The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 amended the Medicare statute by placing limits on payments for patients discharged from IRFs. Amendments to the Social Security Act in 1983 established a PPS for hospitals, but specifically excluded most PAC settings. TEFRA remained the payment system for IRFs from 1982 to 2001. TEFRA reimbursed PAC providers on a cost basis, based on reasonable costs incurred while providing services. However, costs were limited to a base-line facility-specific target amount per discharge, which sometimes led to disparities in reimbursements between older and newer rehabilitation facilities.

Significant congressional action affecting reimbursement for IRFs since TEFRA includes the BBA of 1997, the BBRA of 1999, the BIPA of 2000, all of which are referenced in the Introduction and Background section of this report, and the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007.

The BBA of 1997 (Public Law 105-33) required the development of PPS for PAC settings, including implementation of a PPS for medical rehabilitation hospitals by October 1, 2000. The BBRA of 1999 (Public Law 106-113) required the Secretary of HHS to use the discharge as the payment unit for IRFs and to establish classes of patient discharges by Functional Related Groups (FRGs). The BIPA of 2000 (Public Law 106-554) allowed rehabilitation facilities to elect how they wanted to be paid during the transition period between TEFRA and the IRF PPS.¹¹³

The IRF PPS utilizes information collected in the IRF-PAI to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, with adjustments for case and facility level.¹¹⁴ CMS' goal for facilities to qualify as an IRF under the PPS was that by July 1, 2008, at least 75% of the inpatients in the facility had to be being treated for at least one of a number of qualifying medical conditions.¹¹⁵ However, the Medicare, Medicaid, and SCHIP Extension Act of 2007 stipulated that CMS could set the compliance rate at no higher than 60%.

The Proposed Rule establishing the IRF PPS was published in the November 3, 2000 Federal Register. At the time the rule was published, HCFA entered into agreements with both the UBFA and CareData.com, Inc. to obtain UDSMR^® and Clinical Outcomes System patient assessment data, both based on the Functional Independence Measure (FIM). In the Final Rule, published in the August 7, 2001 Federal Register, the agency, now the CMS,referred to this assessment data collectively as "FIM data."¹¹⁶ In the proposed rule, HCFA had proposed adoption of the MDS-PAC as the instrument to be used for patient assessment. However, following a comparison study of MDS-PAC with the FIM, and responding to concerns expressed about the length of time it took to complete the MDS-PAC and the burden of collecting data using a separate instrument, given that some facilities were already using the FIM for accreditation purposes, CMS announced in the Final Rule that the assessment instrument would be based on the FIM. The instrument was termed "a slightly modified version of the UDSMR patient assessment instrument", which was to be incorporated into the IRF-PAI to serve as the data collection instrument on which the PPS would be based.¹¹⁷

The Final Rule for a Prospective Payment System for Inpatient Rehabilitation Facilities was published August 7, 2001. In the rule, along with the announcement that the assessment instrument would be based on the Functional Independence Measure, HCFA wrote: "We have by no means abandoned our goal of ultimately establishing a common system to assess patient characteristics and care needs for all post-acute care services and pursing [sic] more integrated approaches to their payment and delivery."¹¹⁸

Electronic submission of data, using software provided by HCFA, was also required in the final rule. Assessment data was to be submitted via the Medicare Data Collection Network (MDCN). In compliance with the Paperwork Reduction Act, the "Notice of New System of Records," for the IRF PAI was published in the Federal Registeron November 9, 2001.¹¹⁹

Creation and Development of the IRF-PAI

The IRF-PAI was created for use by facilities subject to CMS’s payment system for Medicare inpatient rehabilitation services. The Functional Independence Measure (FIM), on which it is largely based, was developed prior to that, as a standardized way of measuring the progress of patients undergoing medical rehabilitation.

In 1983, the American Congress of Rehabilitation Medicine (ACRM) and the American Academy of Physical Medicine and Rehabilitation (AAPM&R) appointed a national task force of experts in the medical rehabilitation field to develop a uniform medical rehabilitation data system for documenting outcomes and costs of medical rehabilitation.¹²⁰ The work of the task force was originally funded by the National Association of Rehabilitation Facilities (NARF). In order to facilitate the mission of the task force, ACRM and AAPM&R endorsed applying for a development grant from the National Institute of Handicapped Research of the U.S. Department of Education.¹²¹ The grant for developing and field-testing a functional independence measure was applied for and coordinated through the State University of New York at Buffalo. The grant work was supported by 12 national organizations in various rehabilitation specialties who either sponsored, endorsed, or participated in the development of the data system.¹²²

Since the aim was to create a uniform medical rehabilitation data "system," the grant was intended to support both the development of the assessment instrument and the creation of a data management service.

Although the assessment instrument was designed primarily to measure functional status to inform rehabilitative care, it was envisioned that the data system would be useful for purposes beyond clinical care. The project overview read:

The principal uses of such data are expected to be justification for payment of services, accreditation, quality assurance, evaluation of service innovations based on research and development, estimation of cost benefit and cost effectiveness of rehabilitation services, and more uniform and objective education and training of rehabilitation practitioners.¹²³

The task force identified and reviewed both published and unpublished existing functional assessment instruments in order to come to a consensus on a common data set and measure of disability.¹²⁴ From the beginning, there were concerns about the proprietary nature of existing tools, because acceptance of the instrument by rehabilitation facilities and a willingness on their part to submit data to a centralized location for storage and analysis was vital to the vision of a uniform national data system."¹²⁵ The task force and representatives from the sponsoring organizations concurred on a need for a common repository to store information supplied by individual facilities, but how this was to be accomplished and regulated was a concern.

NARF, the American Hospital Association, and the National Easter Society co-authored a letter to project staff expressing their concern over the development of another proprietary software system, although they understood that without the means for collecting the data in a centralized location, it would be impossible to implement a uniform national data system. The task force was also concerned about the issues of public domain, access to data, impact on the industry, and copyrights to the data management system.¹²⁶

In the grant proposal, it was envisioned that a sub-contractor for the data management service would be identified through a Request for Proposal (RFP). However, instead of putting out an RFP, the Task Force recommended that the project office for the grant proposal at the State University of New York at Buffalo create the data management system.¹²⁷ It was anticipated that it would be three years before the data system could operate independently of grant support, at which time care facilities would bear the costs of maintaining the data service. The grant proposal stated: "It is likely that successful long-term maintenance of the national data system will be best achieved when one of several appropriate advocacy or regulating bodies assumes sponsorship of the system."¹²⁸

Although there is significant dispute about whether the Task Force or researchers at the University of Buffalo "authored" the Functional Independence Measure, many accounts, as reflected by the literature in the rehabilitation field, as well as evidence produced in an the trademark case for the FIM, attribute a key role to the members of the task force.¹²⁹ The minutes from the February 26, 1984 meeting of the Joint Task Force read: "At this point the Task Force split into three groups. The first group worked on identifying the demographics and supplemental measures to be collected, and coding system and instructions…. The second group of the Task Force members met to review available published functional assessment instruments, determine the most common functional status items and recommend items for a national data system, decide on how the functional status items should be grouped and whether additional optional items could be added, and to review functional status rating scales and recommend a common rating scale."¹³⁰ Testimony in support of the Applicant (UBFA, Inc.) in the FIM trademarks case before the Trademark Trial and Appeal Board of the U.S. Patents and Trademarks Office, appears to contradict the meeting notes: "The National Advisory Committee was made up of representatives within the field of rehabilitation medicine selected and invited by UDSMR to function solely in an advisory capacity. The National Advisory Committee had no relationship with UB Foundation Activities, Inc. UDSMR is a division of UB Foundation Activities, Inc."¹³¹

Testimony on behalf of the Foundation in the trademark case credited Dr. Granger with being the primary creator and developer of the assessment instrument and the person who coined the term FIM. The American Medical Rehabilitation Providers Association (AMRPA), the Opposer in the trademark case to granting trademark status to the FIM, disputed the claims that the task force served only an advisory role.¹³²

Text in the grant proposal read: "The proposed Uniform National Data System for Medical Rehabilitation will be developed by a Task Force of recognized experts in rehabilitation care, administration, research and evaluation, and coordinated through the resources of the State University of New York at Buffalo." Dr. Carl Granger, of the University at Buffalo was the Project Director, and Dr. Byron Hamilton, of the Rehabilitation Institute in Chicago was the Principal Investigator. The grant proposal stated that Dr. Granger and Dr. Hamilton "will draft, pilot, and field test the instrument and then refine it based on consultation in Chicago with the panel of experts." The grant proposal also stated that "The ACRM/AAPM&R Task Force (of which Dr. Granger was co-chair) and the ASIA/Spinal Cord Injury Model System consultants … will be responsible for developing the instrument and for subsequent revisions."¹³³

The grant and its extension for the development and implementation of the Functional Independence Measure and the creation of a data management service ran from September 30, 1984 to September 29, 1987. The development of the software and the data management system were envisioned to take place during the second and third years of the project, but staff at the University of Buffalo had already begun working on the software prior to the end of the first year of the contract.¹³⁴ The data management system created was originally called the Uniform Data System (UDS), and subsequently became UDSMR^®.

As with other PAC assessment instruments, the history of the FIM is closely entwined with the history of the PPS for the care setting. For a quick summary, the Functional Independence Measure was developed in the middle 1980s, with funding from the U.S. Department of Education, to address the functional status of patients in rehabilitation facilities. In 1987, under contract to HCFA, RAND and the Medical College of Wisconsin investigated UDSMR^® data and found that functional status instead of diagnoses alone did a better job of explaining total costs of caring for rehabilitation patients. In 1993, FRGs were developed by researchers at the VA Medical Center in Los Angeles as a possible basis for a PPS.¹³⁵ In 1994, researchers at the University of Pennsylvania refined the FRGs by applying them to a large database of patient rehabilitation data maintained by UDSMR^®.¹³⁶ In 1995, RAND, again under contract to HCFA, used UDSMR^® data to study the FRGs and found that they remained stable over time and could be used as a case mix methodology for a PPS.¹³⁷ In 1997, HCFA published the criteria for a IRF PPS, and the Secretary of HHS established case mix groups, required IRFs to submit data to establish and administer the PPS, provided a computerized data system for group patients for payment, and provided software for data transmission. In 1999, the BBRA refined the PPS for IRFs, amending the Social Security Act to require the Secretary of HHS to base the case-mix groups on criteria deemed "appropriate to improve the explanatory power of functional independence measure-function related groups.¹³⁸ Also in 1999, MedPAC issued a report urging Congress to implement an IRF-PPS as soon as possible and recommended that the PPS be based on the "FIM-FRG classification system."¹³⁹

Intellectual Property Issues

UDS (later UDSMR^®), a division of UBFA, was formed on October 1, 1987. UBFA, a New York not-for-profit corporation, claims exclusive ownership of the Functional Independence Measure (FIM^® instrument). The Research Foundation of the State University of New York (SUNY) originally claimed ownership of the FIM, with rights being transferred to UBFA "in order to facilitate proper protection and licensing of the FIM System."¹⁴⁰ UDSMR^® provides teaching workshops and data management services through their FIM^® System. Most IRFs in the United States subscribe to UDSMR^® services.¹⁴¹

Any use of the FIM, other than for reimbursement from CMS authorized through license agreements signed between UBFA and HCFA (in 1995) and CMS (in 2002), requires a license agreement with UDSMR^®. Vendors who incorporate the FIM^® portions of the IRF-PAI into products may do so only with a license agreement with UDSMR^®.¹⁴² UDSMR^® offers a number of different kinds of licenses for use of the FIM^® instrument, all of which, including use of the FIM for research purposes, require a license fee. Academics who want to use the FIM for research or educational purposes need to sign research licenses with UDSMR^®, identify the FIM as required by UDSMR^®, and present the results of their research to UDSMR^® for review. Research letters of agreement are available for students, as well as for large-scale or collaborative research projects carried out by researchers in the field. In order to qualify for a research license to use the FIM for research or educational purposes, UDSMR^® requires the individual or entity to complete and return to UDSMR^® a research tracking form, including an abstract or description of the project along with the proposed use of the FIM in the project. If the request is approved by the UDSMR^® research committee, the licensee:

will be asked to conform to established criteria regarding use of service marks and trademarks, as well as established standards with respect to references to materials copyrighted or registered by UDSMR. The entity will also be required to sign a written agreement that serves to protect intellectual property rights as well as formally establish responsibilities of both parties with respect to use and dissemination of UDSMR data and copyrighted materials.

A licensing fee is assessed for each research request approved. Also, licensees using the FIM are required when reporting results to indicate whether they have taken and passed the UDSMR mastery level test.¹⁴³

UDSMR^® offers annual licenses to health care facilities for use of the FIM^® instrument and data collection software. A limited license for a defined period of time is also available to facilities not currently subscribing to UDSMR^® services, with the expectation that a long-term relationship would develop. This license allows a facility to test the FIM^® System to determine clinical usefulness. There are fees associated with license agreements for these pilot projects. Subscribers are required to acknowledge that UDSMR^® owns the FIM.¹⁴⁴

Geographical areas also can license the FIM^® system. Territorial licenses include training and distribution agreements for marketing and distributing FIM^® materials and for provision of FIM^® training for UDSMR^® subscribers in that region. Licensing arrangement with countries also may include a database license for the purpose of using the FIM^® instrument for aggregating data and providing statistical reports within the country.¹⁴⁵

Software companies who have licensed the FIM for use have been given permission to use the FIM as long as software screen pages properly incorporate the FIM^® service and trademarks. A typical letter agreement between UDSMR^® and a software company states:

You have asked for UDSMR’s permission to incorporate descriptive and definitional elements of the FIM System. UDSMR is willing to grant to you permission to use and incorporate the FIM System into your software upon the terms and conditions set forth in this letter agreement…

1. UDSMR hereby grants to you the right to incorporate some or all of the description, definitional and other terms comprising the FIM System…

2. In consideration of and as a condition to the rights granted to you pursuant to this letter agreement, you shall take all steps reasonable and necessary to acknowledge UDSMR’s ownership rights to the FIM System. Without limiting the generality of the preceding sentence, a notice substantially in the form set forth should be incorporated into and appear (a) on introductory screen displays as well as any screens which make specific reference to or which introduce any sub-routines that incorporate any elements of the FIM System and (b) in any manuals or documentation relating to said software…. “The Uniform Data Set and the Functional Independence Measure are proprietary products of UB Foundation Activities, Inc.”

3. You shall provide to UDSMR upon request, samples of proposed screen layouts and other portions of text containing elements of the FIM^® System or containing the foregoing notice.¹⁴⁶

The requirement regarding furnishing UDSMR^® with screen displays of the acknowledgments of copyright, trademarks, and service marks continues to be part of the License Agreement with UDSMR^® for incorporation of the FIM into software.

In a 2002 Addendum to the 1995 License Agreement with HCFA, UDSMR^® agreed to develop and update on a periodic basis the IRF-PAI Training Manual. UDSMR^® claims compilation rights to the manual, and also provides training and help desk support for IRF-PAI issues, presumably under contract with CMS.¹⁴⁷

The “FIM^® system,” including the data set, definitions, documentation, and software for storing and analyzing the data, is maintained by UDSMR^®, which has licensed the system since 1994. The number of subscribers in 1994 was 622, which by 2009 had grown to 1400. Revenues for use of the FIM and "the FIM^® System" goods and services are in the seven million dollar range.¹⁴⁸

UDSMR^® requires that in order to be called “FIM^® data,” the data must be collected by trained clinicians and sent to UDSMR^® for analysis.

Data management services are performed by UDSMR. To include facility data in the aggregate reports, UDSMR requires that the data be credentialed through a two-step process that requires clinicians who are reporting data to demonstrate understanding of rating with the FIM instrument by passing a mastery test and by subjecting the data to analysis of each subscribing facility for outlier variables.¹⁴⁹

Facilities retain ownership in the data they send to UDSMR^®, but there are limitations to the uses they can make of UDSMR^®-analyzed data:

When facilities subscribing to UDSMR^SM compare results of their own programs with those of the national aggregate, they should be aware that the aggregated regional and national data from their UDSMR reports are copyrighted and owned by the University at Buffalo Foundation Activities, Inc., State University of New York at Buffalo, and must be used according to the UDSMR service agreements and contracts.¹⁵⁰

Unlike the MDS and OASIS, neither the FIM^® data set nor the IRF-PAI assessment instrument is represented in either UMLS or LOINC.

Intellectual Property Notices Displayed by the CMS

CMS accepts the assertion by the University at Buffalo Foundation Activities, Inc. (UBFA) that they own the Functional Independence Measure (FIM). UBFA’s copyright notice appears in the final rule for the IRF PPS published in the Federal Register August 7, 2001. The copyright notice also appears on the CMS web site.¹⁵¹ The text of the copyright notice reads as follows:

The FIM data set, measurement scale and impairment codes incorporated or referenced in the IRF PAI are the property of UB Foundation Activities, Inc.^© 1993, 2001 UB Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.

UBFA's copyright notice also appears on every page of the 244-page training manual available for download from the UDSMR web site.¹⁵² The text of the copyright notice in the training manual reads as follows:

Copyright ^© 2001-2004 UB Foundation Activities, Inc. (UBFA, Inc.) for compilation rights; no copyrights claimed in U.S. government works included in Section I, portions of Section IV, Appendices I and K, and portions of Appendices B, C, E, G, H and J. All other copyrights are reserved to their respective owners. Copyright ^© 1993-2001 UB Foundation Activities, Inc. for the FIM Data Set, Measurement Scale, Impairment Codes, and refinements thereto for the IRF-PAI, and for the Guide for the Uniform Data Set for Medical Rehabilitation, as incorporated or referenced herein. The FIM mark is owned by UBFA, Inc.

Intellectual Property Notices Displayed by UDSMR^®

The UDSMR^® web site displays the following copyright notice:

The Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities Inc., is the developer and sole owner of the copyrighted assessment tool known as the FIM™ Instrument. As the owner, UDSMR only grants permission to use the FIM™ instrument though a variety of licensing arrangements. The intended use of the instrument dictates the level of licensure and the associated rights and fees.¹⁵³

UBFA License Agreements with HCFA and CMS

In September 1995, UBFA and HCFA entered into a agreement that allowed HCFA to study the Functional Independence Measures as a basis for the IRFs PPS. Addenda to the September agreement were signed in November 1995, and again in February 2002. The license had two distinct phases -- one was to evaluate the FIM^® System as the basis for the PPS. The second phase covered the terms of the agreement should HCFA decide to use the FIM for the PPS.

The license agreement gave HCFA the right to use the FIM^® instrument and related materials in the development, design, and evaluation of the PPS. As interpreted by UBFA, the agreement permitted "HCFA to sublicense hospitals to use the FIM^TMinstrument and related materials 'without fee or obligation to UDSMR' as part of the Medicare-payment system."¹⁵⁴

The agreement did not limit the use of the FIM to reimbursement, but the use had to be related to the payment system. Clause 2(b)(iv) gave HCFA the right "to use the Licensed System for other HCFA program needs related to the Payment System, including quality assurance, hospital certification and research." In the agreement, the parties also agreed "that discharge data, provider data, or other data and products derived from and specifically related to the Payment System, including but not limited to data or other products relating to quality assurance, hospital certification, or research derived from or relating to the Payment System, shall be subject to public disclosure and use for purposes of the Payment System, notwithstanding that such data or products incorporate any portion of the Licensed System."¹⁵⁵

UDSMR^® viewed the agreement as giving HCFA the "right to use the FIM instrument and related materials and to license one or more third-parties to use UDS system 'in connection with the development, design, implementation, maintenance, operation, and evaluation of the [Medicare] Payment System.' Specifically, the License Agreement permits HCFA to sublicense hospitals to use the FIM^TM instrument and related materials 'without fee or obligation to UDSMR' as part of the Medicare-payment system." [emphasis theirs]¹⁵⁶

In a 2002 clarification letter to an employee at HHS/ASPE regarding legitimate use of the FIM, the Director of UDSMR^® wrote:

Under the License Agreement, the only authorized users of the portions of the Training Manual contributed by UDSMR are CMS, UDSMR and the inpatient rehabilitation facilities subject to the payment system. UDSMR has made these materials available to CMS and the facilities on a completely royalty-free basis. However, the right to use them does not extend to the 'regulatory community' in general, as AMRPA erroneously states.¹⁵⁷

The letter continued:

As you may be aware, UDSMR worked closely with CMS’s attorneys to develop the copyright notice for the Training Manual. It has been carefully crafted to indicate that some sections and appendices of the Training Manual have been wholly developed by either UDSMR or CMS, while others reflect contributions from both and/or other parties.

The AMRPA had suggested that the copyright notice was confusing and that it was not necessary to put it on every page of the training manual.

In response, the Director of UDSMR^® wrote:

AMRPA’s letter highlights the need for a brief explanation of the ownership issues relating to the Training Manual and the related Inpatient Rehabilitation Assessment Instrument on CMS’s website. We have made this suggestion to CMS on numerous occasions. We believe that many of AMRPA’s concerns would be addressed if CMS were to place a notice similar to the following on its website:

"The Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) and the IRF-PAI Training Manual were created for use by facilities subject to CMS’s payment system for Medicare inpatient rehabilitation services. The IRF-PAI and the Training Manual contain proprietary material that was incorporated with the express permission of the owners. Anyone other than a facility subject to the payment system who wishes to use the IRF-PAI or the Training Manual should contact such owners prior to any such use."¹⁵⁸

Portions of the license agreements between HCFA (and subsequently CMS) and UBFA, which limited how and for what purposes the FIM could be used, appear to be in direct contradiction to the Code of Federal Regulations and OMB Circular A-110 grant rules under which the FIM was developed, and rules to which UDSMR^® points as justification of their copyrights.¹⁵⁹

The 1995 license gave HCFA the right to modify the instrument. The amended license signed in 2002 limited CMS's (HCFA's successor) rights to modify the instrument without first consulting with UDSMR^®, and asserted that "any such modification shall only be for the purpose of carrying out CMS’s tasks relating to the Payment System…."¹⁶⁰

The IP rights section of the 1995 agreement outlines how HCFA must acknowledge UDSMR^® ownership of the FIM:

5. Intellectual property

(a) HCFA acknowledges that all right, title and interest in and to the Licensed System, the Marks, and all copyrights shall remain the sole and exclusive property of UDSMR. To the extent permitted by federal law, HCFA's use of the Licensed System and the Marks shall inure to the benefit of UDSMR, and this Agreement shall not operate to transfer or convey to HCFA or to any Third Party any ownership interest whatsoever in the Licensed System, the Marks or any derivative works thereof created by UDSMR.

(b) HCFA shall take all steps reasonable and necessary to acknowledge UDSMR's ownership and copyright rights to the Licensed System and the Marks. Without limiting the generality of the preceding sentence, notices substantially in the forms set forth below or any successor notices shall be incorporated into and appear in any printed or published documentation or other tangible materials relating to or resulting from the exercise by HCFA of its rights and licenses under this Agreement insofar as any such materials refer to or incorporate any portion of the Licensed System.

"The FIM^SM data set, measurement scale and impairment codes incorporated or referenced herein are the property of UB Foundation Activities, Inc."

"The FIM^SM service mark is owned by UB Foundation Activities, Inc.

In addition, any such materials which substantially reproduce the Data Set, the Adult FIM Scale or the Impairment Codes from the Guide, or any other copyrighted UDSMR materials, shall contain the following copyright notice: "Copyright 1993 UB Foundation Activities, Inc.", or any successor notice.

(c) To the extent HCFA has the requisite right and license, and the authority to grant such right and license, HCFA agrees to grant to UDSMR an unconditional, irrevocable and nonexclusive right and license to use, to modify and to sublicense others to use and modify any modifications, enhancements, improvements or other derivative works made to, or based upon, the Licensed System by HCFA or any of its sub licensees."¹⁶¹

The 2002 addendum to the agreement added the following sentence to Section 5(b) of the 1995 license. "CMS shall also include the copyright notice contained in the Training Manual in any reproduction of the Training Manual in whole or in part, regardless of the medium in which such reproduction is made."¹⁶²

Between the time that UDSMR^® and HCFA signed the 1995 license agreement, and while awaiting the report from RAND, with whom CMS contracted to analyze the Functional Independence Measure and Function Related Groups (FRGs) for use in the PPS, UDSMR^® issued a position statement, prompted by concerns expressed by the rehabilitation community that UDSMR^® was standing in the way of a PPS based on the FIM and the FIM/FRGs. UDSMR^® was reticent to let the RAND study be published without UDSMR^® edits, based on what they saw as the unauthorized publication of proprietary information:

The present issue with HCFA over publication of the RAND reports involves the protection of UDSMR's intellectual property rights under its agreements with HCFA. The premature dissemination of the draft reports without UDSMR's consent has already led to improper commercial exploitation by third parties of the information contained in those reports, and UDSMR seeks only to avoid further breaches of its proprietary rights. UDSMR has requested deletion of certain information for purposes of general publication, and had agreed to make the full reports available subject to appropriate terms and conditions. [emphasis theirs]¹⁶³

In the position statement, UDSMR^® writes:

Although Dr. Granger has always believed strongly in the free flow of ideas among researchers and others, UDSMR has had no choice but to take steps to protect the FIM instrument and data so valuable to the field and to UDSMR's subscribers.

Analysis of IRF-PAI Intellectual Property Issues

Sorting out the IP issues with respect to the IRF-PAI is not easy. The IRF-PAI is a government document, based largely on the Functional Independence Measure (FIM) of which UBFA claims ownership. Whether the claim is legitimate or not is a matter of dispute. HCFA's agreement to “license” the FIM and to print UBFA’s copyright claims on their web site, in the Federal Register final rule, and on every page of the IRF-PAI user’s manual, lends legitimacy to the ownership claims. As Trosow writes, "once copyright attaches to a work, there can be significant negative consequences for downstream access to that work."¹⁶⁴

On the coding form, UBFA claims copyrights to all parts of the IRF-PAI except for the medical needs and quality indicators sections. The copyrighted portions include Identification Information, Admission Information, Payer Information, Medical Information, Function Modifiers, FIM^TM Instrument, and Discharge Information.

Ownership of the FIM has been challenged in at least two legal cases. A challenge to the trademarking of FIM was settled by the Trademark Trial and Appeal Board of the U.S. Patent and Trademark Office in UBFA’s favor, giving them the right to trademark FIM^® and the FIM system^®.¹⁶⁵ A dispute before the Federal District Court in Western New York has been ongoing since 2003 and, barring an unlikely settlement between the parties, is slated to come to a jury trial in 2010. The original defendant in the case (there has been a countersuit) claims UBFA has admitted they don't own the copyright to the FIM, although it is not clear that has been stipulated by the plaintiff. The dispute now appears to be focused more on restraint of trade and monopolization issues, but ownership of the FIM is a key issue. Part of the problem in these cases appears to be an expanding definition of what is being claimed as IP, whether it was the data collected and analyzed using the FIM^® instrument, the software used to collect and store the data, the user and training manuals (which at some point began adding "including the FIM^® instrument" to the title), the "FIM system^®," or the FIM^® data set itself. Over the years, the definition appears to have grown to include all of the above.¹⁶⁶ A 2006 study by the Division of Health Care Policy and Research at the University of Colorado at Denver and Health Sciences Center described the system as such: "The UDSMR^® consists of four components: (1) a data set used to assess disability severity and medical rehabilitation outcomes; (2) computer software; (3) a data management service for subscribing facilities; and (4) a training program for users."¹⁶⁷

From the beginning, a complicating factor was the fact that one of the co-chairs of the Task Force was the project director on the grant and also a faculty member in the Department of Rehabilitation Medicine at the State University of New York at Buffalo, the recipient of the grant from the U.S. Department of Education. Another complicating factor was the intention in the grant proposal to issue an RFP for a software company to create software designed for locating, interpreting, and reporting the data. However, the RFP was never issued because the task force decided that the University at Buffalo was equipped to carry out the task.¹⁶⁸ As the assessment tool was accepted, data accumulated, and software developed, the analysis of which became a profitable business, ownership rights to the software and analyzed data became entangled with ownership rights to the FIM itself, since the FIM was not only integral to the software and related documentation, but also to derivative products created by UDSMR^® (e.g., FIMware^®, weeFIM^®).¹⁶⁹

Also confusing the issue were conflicting statements from UDSMR^® concerning who owned the tool and whether it was in the public domain. Reviewing contemporary correspondence and other materials produced as evidence in the Trademarks case, it is unclear when UBFA began to assert their IP rights, but it is clear that, from the beginning, this was an issue hovering below the surface. In the grant extension proposal in 1985, under the "Inventions and Copyrights" section, the proposal states: "It was too early to consider copyrighting the National Data Set."¹⁷⁰

An undated draft of a UDSMR brochure entitled “Why Uniform Data Now?” stated:

With the development of the Uniform Data System for Medical Rehabilitation (UDSMR) clinicians are now able to document the severity of patient disability and results of the medical rehabilitation process. The national task force which created the much-needed system is co-sponsored by the American Congress of Rehabilitation Medicine and American Academy of Physical Medicine and American Academy of Physical Medicine and Rehabilitation.¹⁷¹

Other statements made during this period include a 1986 letter by Carl Granger in which he wrote:

I certainly confirm that the coding sheet of the Uniform Data System (UDS) is in the public domain. We have worked very diligently to obtain national consensus regarding the assessment items and have a detailed and scientifically rigorous method for evaluating the reliability, validity, and precision of the Functional Independence Measure (FIM) component. Therefore, we have copyrighted the coding sheet to preserve its integrity while we promote its use as widely as possible.¹⁷²

In correspondence with a company called Formations in Health care, Inc., UDSMR^®, through their attorney wrote:

With respect to the "FIM" mark, it is neither descriptive nor generic, but rather a coined phrase which UDSMR has adopted and is using in connection with its business. This is legally protectable trademark use which UDSMR intends to enforce as its exclusive right for its business purposes. There are no barriers to its claim to ownership. …With respect to copyrightability of the Functional Independence Measure itself, it is clear under the Copyright Act that the measurement device, and the manner of its definition, including the instrument and item definitions are copyrightable subject matter under Section 102 of that Act, as original works of authorship in the category of literary works. It is equally clear that ownership of those copyrights is properly and legitimately claimed by the Research Foundation of the State University of New York and/or by the UDSMR division of the UB Foundation Activities, Inc., as their respective rights may appear.¹⁷³

A document presented for exhibit in the case before the Trademark Trial and Appeal Board, stated:

All copyrights, service marks and trademarks relating to the FIM System^SM are owned by UBFA and none of the FIM System^SM is or has ever been in the public domain. Any unauthorized or unlicensed incorporation of portions of copyrighted works relating to the FIM System^SM into other works, any modification of any such modified works by third parties and any unauthorized or unlicensed use of any such copyrighted works or of the UDSMR or FIM service marks or trademarks are and remain inproper and in violation of UDSMR's intellectual property rights. (Trademark dispute case, p.207 OPP-47.)

Correspondence between Kenneth Aitchinson, chair of an AMRPA PPS Task Force and Carl Granger in April 1998 included this exchange:

Aitchinson: "We are in a very critical period in the development of a PPS for rehab and AMRPA is, as you know, mounting a major campaign to influence the outcome. We need to be sure that there be no misunderstanding…." At the Task Force meeting on January 19, Jim [Phillips, of UDSMR] was asked specifically… whether [UDS] would assert proprietary rights to the FIM or portions thereof if it was used by HCFA, in whole or in part, as an element of a new MDS instrument. Jim assured us that there was no problem… and the HCFA had complete license to use the FIM or items therefrom. Based on those assurances AMRPA developed the policy position set forth in the attachment."¹⁷⁴

Granger's response was: "We are in communication with John Morris, the HCFA contractor, for the MDS-PAC and these issues are being discussed and analyzed. He understands that no barriers exist under the license agreement between UDSMR and HCFA.¹⁷⁵

In a 1999 letter, UDSMR^® made the statement that:

…the FIM^TM instrument and all other aspects of the FIM system is owned by UDSMR, and that no part of the FIM system is or ever has been in the public domain. UDSMR has entered into numerous licensing arrangements granting licensees the right to use the FIM instrument and related materials for a variety of purposes. Unfortunately, UDSMR must from time to time take action with respect to researchers and service providers who are ignorant of, or choose to ignore, UDSMR's ownership rights in the FIM System.¹⁷⁶

E-mail correspondence between the VA and UDSMR^® with the subject line "copyright question," indicates that the VA was confused about the proprietary nature of the FIM. A response from UDSMR^® to an e-mail inquiry from the VA with the subject line "Copyright question" read:

I am sending this email to you in response to a question you had given to Dr. Carl Granger regarding UDSMR's ownership in the IRF-PAI. In answer to your concerns, CMS (formerly HCFA) has a license agreement with UDSMR under which CMS has UDSMR's permission to use elements of the FIM[TM] instrument in connection with the IRF-PAI. UDSMR, however, retains all ownership rights in and to the FIM[TM] instrument.¹⁷⁷

The VA Medical System subscribes to the FIM^®instrument and UDSMR^®.¹⁷⁸ However, the VA User's Manual for the FIM, developed for use with the the VA's electronic health care system, VistA, dated May 2003, makes no mention of the copyright issue, or of UDSMR^® or UBFA, Inc.¹⁷⁹

The Functional Independence Measure (FIM) is likely copyrightable, but it is unclear that UDSMR^® has exclusive rights as to how the FIM can be used. If UBFA has legitimately copyrighted the FIM, based on rules published in the OMB circular (A-110) and title 34 of the Code of Federal Regulations concerning "intangible property" created through government grants (in this case, the U.S. Department of Education), it is unclear, based on the same rules, how they have justified the restrictions they have placed on HCFA's and CMS's use, unless it is simply a technical matter that the grant was through the U.S. Department of Education and not the HHS.

UBFA, Inc. has not had an easy time asserting their exclusive rights to the FIM. That being the case, it is hard to surmise whether they would be inclined to permit the creation and dissemination of HIT-coded versions of the FIM, simply because the policing of unauthorized use could prove to be burdensome. Despite the ubiquitous copyright notices, it appears that many continue to be unaware, or doubtful of the legitimacy of UBFA's claims to the FIM, even though most people in the rehabilitation field are likely familiar with UDSMR^® and their data services.

While it is not possible with currently available documentary evidence to sort out the ownership claims and counterclaims to determine the IP issues that will arise if standards organization wish to apply HIT standards to the instrument and disseminate a standardized IRF-PAI, some further analysis of where we have been and how we got here as described in "Medicare Funding for Inpatient Rehabilitation: How Did We Get to This Point and What Do We Do Now?" may be informative.¹⁸⁰ It should be noted however, that the work underway in CMS to develop a new patient assessment instrument, the CARE instrument, may eliminate the need to rely on the FIM^® data elements for Medicare payment purposes if the data elements in the CARE instrument are found to support appropriate Medicare payment algorithms for IRFs.

Follow Up And Additional Research

Additional discussions and research may provide further insight into the various IP issues addressed above. Conversations with the leadership at the NLM, the Regenstrief Institute, the interRAI consortium, UDSMR^®, and the Center for Health Services Research at the University of Colorado, may prove helpful for future development and standardization of federally-required assessment instruments. It would be instructive to understand how the Regenstrief Institute was able to address interRAI’s international licensure constraints when incorporating the MDS into LOINC and whether any other IP issues remain in applying and disseminating accepted HIT standards to MDS patient assessments. Further, these conversations could shed light on issues that will likely be faced should there be an effort to apply CHI standards to the IRF-PAI. These discussions maysuggest useful steps that could be taken to minimize or eliminate IP issues in the development of future assessment instruments.

The terms of past contracts under which assessment instruments and related documentation were developed may inform how future contracts could be written so that data collection instruments developed for government use remain in the public domain. In particular, incorporating the "special works" clause of the Federal Acquisitions Regulations (FAR) into contracts would give the government the ability to limit the contractor's rights to claim ownership in content first produced through the contract. It would also allow the contracting agency to direct the contractor to establish a copyright claim and assign the copyright to the government, which would give the government unlimited rights in how the instruments are released and used.¹⁸¹

Preliminary conversations indicate that CMS is fully aware of many of the issues that can arise when federally-required assessment instruments are not freely available in the public domain, including concerns that IP claims may constrain the application of HIT standards to these instruments and limit the dissemination of HIT-enabled standardized assessments. Obtaining guidance from those with expertise in applying and disseminating CHI-accepted standards to current assessment instruments developed under federal contracts or grants will facilitate the application and dissemination of HIT standards to emerging assessment instruments, and support the goal of health information exchange and system interoperability.

A number of organizations have commented to CMS on the non-interoperable nature of the specifications for the electronic transmission of patient assessment data, and have recommended that code formats be consistent across the various assessment instruments, encouraging CMS, for example, to adopt the HL7 Patient Assessment Questionnaire and Clinical Document Architecture (CDA) instead of using a custom-designed data transmission tool, stating “Rather than developing a custom based data transmission process,… CMS [should] reevaluate the benefits and usage of CDA for the MDS 3.0 including the applicable content standards (LOINC and SNOMED-CT).¹⁸²

Efforts are underway to create a system for all PAC assessments using consistent terminology. The instrument being developed is the CARE which aims to harmonize data elements across the three assessment tools CMS currently requires. The National Quality Forum is also calling for harmonization of assessment items in the areas they are addressing as part of their quality initiatives.

A major piece of legislation from 2009 with broad implications for health care delivery and health information exchange was the ARRA, also known as the “stimulus bill.” Provisions in the HITECH section of the Act address incentives for the adoption of HIT by health care providers. Although care assessments are not addressed specifically in the wide-ranging act, the Act is likely to significantly impact health information exchange and the use of certified EHRs. The stimulus plan provides significant funding for EHR adoption by some healthcare providers. While ARRA's definition of health care providers includes SNFs, nursing facilities, home health entities and other LTC facilities, these providers are not yet slated to receive the same incentive payments physicians and hospitals will be eligible for if they are able to demonstrate "meaningful use" of HIT. However, with the ONC investigating how to expand HIT adoption incentives to other providers and industry movement towards certification of PAC electronic records, significant opportunities exist to leverage federally mandated functional assessment tools to drive the interoperability required in the stimulus bill. Standardizing the data sets in these assessments is an important first step towards achieving that interoperability.

Acronym List

AAPM&R	American Academy of Physical Medicine and Rehabilitation
ACRM	American Congress of Rehabilitation Medicine
AMRPA	American Medical Rehabilitation Providers Association
ARRA	American Recovery and Reinvestment Act
ASIA	American Spinal Injury Association
ASPE	Office of the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services
BBA	Balanced Budget Amendment of 1997
BBRA	Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
BIPA	Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
CAM	Confusion Assessment Method
CARE	Continuity Assessment Record and Evaluation
CFR	Code of Federal Regulations
CHI	Consolidated Health Informatics Initiative
CIHI	Canadian Institute for Health Information
CMS	Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services (formerly HCFA)
CoP	Medicare Conditions of Participation
CPS	Cognitive Performance Scale
DRA	Deficit Reduction Act of 2005
EHR	Electronic health record
FAR	Federal Acquisition Regulations
FHA	Federal Health Architecture
FIM®	Functional Independence Measure
FR	Federal Register
FRGs	Functional Related Groups
HCFA	Health Care Financing Administration (predecessor to CMS)
HHA	Home health agency
HHS	U.S. Department of Health and Human Services
HIT	Health information technology
HITPC	Health IT Policy Council
HITSP	Healthcare Information Technology Standards Panel
HL7	Health Level Seven
HRCA	Hebrew Rehabilitation Center for Aged
IHE	Integrating the Healthcare Enterprise (HIMSS)
interRAI	inter[national]RAI. These are the developers of the MDS.
IOM	Institute of Medicine
IP	Intellectual property
IRF	Inpatient Rehabilitation Facility
IRF-PAI	Inpatient Rehabilitation Facility-Patient Assessment Instrument
LOINC	Logical Observation Identifiers Names and Codes
LTC	Long-term care
LTCH	Long-term care hospital
LTCI	Long-term care insurance [Japan]
MDS	Minimum Data Set
MDS-PAC	Minimum Data Set-Post-Acute Care
NARF	National Association of Rehabilitation Facilities
NCVHS	National Committee on Vital and Health Statistics
NLM	National Library of Medicine
OASIS	Outcome and ASsessment Information Set
OBQI	Outcome-Based Quality Improvement
OBRA	Omnibus Budget Reconciliation Act of 1987
OMB	U.S. Office of Management and Budget
ONC	Office of the National Coordinator for Health Information Technology
PAC	Post-acute care
PHQ	Patient Health Questionnaire
PPS	Prospective Payment System
RAI	Resident Assessment Instrument
RAI-MH	Resident Assessment Instrument for Mental Health
RAI-NH	Resident Assessment Instrument for Nursing Homes [Spain]
RAP	Resident Assessment Protocol
RELMA	Regenstrief LOINC mapping assistant
RFP	Request for Proposal
RTI	Research Triangle Institute
RUG	Resource Utilization Group
SDO	Standards development organization
SNF	Skilled nursing facility
SNOMED-CT	Systematized Nomenclature of Medicine-Clinical Terms
TEFRA	Tax Equity and Fiscal Responsibility Act of 1982
UBFA	University of Buffalo Foundation Activities, Inc.
UDS	Uniform Data System (later became UDSMR)
UDSMR	Uniform National Data System for Medical Rehabilitation
UMLS	Unified Medical Language System
USPTO	U.S. Office of Patents and Trademarks
VA	U.S. Veteran's Administration

Copyrights And Trademarks

Please note that failure to register a copyright does not mean forfeiture of rights in copyrightable works.

MDS/RAI

Copyrights:

A number of individuals and publishers have claimed copyrights to what appear to be derivative works that include or reference the MDS (e.g., forms, compilations with added texts, training and reference manuals). The following are the only copyrights registered by interRAI.

InterRAI. (1995) Long Term care Resident Assessment Instrument User's Manual: Version 2.0. (Authorship on application: coauthors: John N. Morris, Katherine M. Murphy, Brant E. Fries… et al.; Basis of Claim: New Matter: revisions, additions.)

InterRAI. (1997) RAI-home care (RAI-HC) Assessment Manual. (Authorship on application: co-authors of text: John N. Morris, Brant E. Fries, Roberto Bernabei, R. Knight Steel, pseud., Naoki Ikegami, G. Iain Carpenter & Ruedi Gilgen; Basis of Claim: New Matter: substantial text added to preexisting assessment program.)

Trademarks:

To date, it does not appear that interRAI has sought trademark or service mark protection for any of their instruments.

OASIS

Copyrights:

The following are copyrights registered by the Center for Health Policy Research:

Center for Health Policy Research. (1994a). Measuring Outcomes of Home Health Care: Vol. 1: Final Report, September 1994. Denver: Center for Health Policy Research.

Center for Health Policy Research. (1994b). Objective Review Criteria for Abstracting Data for Clinical Record Review of Home Health Care: Vol. 3, Final Report.

Center for Health Policy Research. (1994c). Technical Appendices to the Report on Measuring Outcomes of Home Health Care: Final Report, September 1994.

Trademarks:

Registrant: Center for Health Services and Policy Research. Word Mark: OASIS GENIE. Goods and Services: "Computer software for use to enter and track information on patient demographics, functional status, and health status, and instruction manuals used in connection therewith." Type of Mark: Trademark. Date of Registration: July 23, 2002.

Irf-pai

Copyrights:

The following are copyrights registered by University of Buffalo Foundation Activities, Inc. (UBFA):

Guide for the Uniform Data Set for Medical Rehabilitation. (1995).

Guide for the Uniform Data Set for Medical Rehabilitation & 2 Other Titles. (1995).

The UDS-PRO System Software and Software Guide, Version 2.0.

UB Foundation Activities, Inc. (1997). Guide for the Uniform Data Set for Medical Rehabilitation (adult FIM^®): Ver. 5.1.

UB Foundation Activities, Inc. (1999). Revised appendices A and B for the Guide for the uniform data set for medical rehabilitation (Adult FIM^®): Version 5.1. (Registration Number/Date: TX0005665330/2002-10-21)

UDSPRO Source.txt.

UDS-PRO System Software and Software Guide 3.01.

UDS-PRO: Software.

Uniform Data System for Medical Rehabilitation. (1998). LIFEware Software.

Uniform Data System for Medical Rehabilitation. (2005). UDS-PRO HL7.

Uniform Data System for Medical Rehabilitation, UB Foundation Activities, Inc., & UB Foundation Activities, Inc. Uniform Data System for Medical Rehabilitation. (2002). IRF-PAI Training Manual.

Uniform Data System for Medical Rehabilitation, UB Foundation Activities, Inc., & UB Foundation Activities, Inc. Uniform Data System for Medical Rehabilitation. (supplement to item registered in 2002). IRF-PAI Training Manual.

Uniform Data System for Medical Rehabilitation, UB Foundation Activities, Inc., & UB Foundation Activities, Inc. Uniform Data System for Medical Rehabilitation. (2005). The UDS-PRO System Software and Software Guide, Version 1.1.

Uniform Data System for Medical Rehabilitation, & UB Foundation Activities, Inc. Uniform Data System for Medical Rehabilitation. (2003). The UDS-PRO Software Data Specification Guide.

University at Buffalo Foundation Activities, Inc. (1994). Guide for the Uniform Data Set for Medical Rehabilitation (adult FIM^®): Version 4.0.

US [sic] Foundation Activities, Inc. (2001). The UDS-PRO System (including the FIM^® Instrument): Clinical Guide, Version 1.0. (Registration Number/Date: TX0005877639/2002-05-27)

WeeFIM® II Software

Trademarks:

Trademark for the mark "FIM". Originally, the registration of FIM was turned down by the U.S. Office of Patents and Trademarks. When UDSMR^® provided further evidence, the USPTO approved the registration of FIM. Subsequently, the American Medical Rehabilitation Providers Association (AMRPA) challenged the trademarking of FIM, but the USPTO ruled in UDSMR's favor in 2009. UBFA claims the following trademarks:

AlphaFIM^®, AlphaFIM Analyzer^®, FIM^®, FIM-PAI^TM, FIMware^®, The FIM System^®, Mini-FIM^TM, LIFEware^®, LIFEware^SM, PAR-PRO^TM, PAR-PRO^SM, Piece of the PAI^®, UDSMR^®, UDS Central^TM, UDS-FIMi^TM, UDSFIM Central^TM, UDSPRO Central^TM , UDS-PRO^®, UDS-PROi^®, UDS-PROi^SM, WeeFIM^®, WeeFIM^®, WeeFIM II^®, WeeFIMware^TM

http://www.udsmr.org/Documents/Trademark-service%20mark.pdf

MDS Stakeholder Letters

July 25, 2003

Barbara Paul, MD
Director
Quality Measurement and Health Assessment Group
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Paul:

The undersigned organizations, representing key constituencies in the Resident Assessment Instrument (RAI) process, would like to request a meeting with you and any staff members you choose to include.

We believe it is critical that we discuss a number of issues regarding revision of the MDS as soon as possible. From our vantage point, the current direction for the instrument’s evolution appears to be leading toward a tool that is increasingly driven primarily by program support needs. We firmly believe that the MDS must retain a resident focus and that the paramount objective in redesign must be to improve the quality of information to facilitate accurate, comprehensive resident assessment and care planning, consistent with the law, current regulations, current standards of practice and the best available science on quality care for the populations served in nursing homes.

While keeping this goal primary in our minds, we must also strive to ensure that the critical information is being collected not only to support current quality measurement and payment needs, but also to ensure that revisions to the system give us the capacity to improve and strengthen these systems in the future through the collection of better data that provides more robust information for these purposes.

Specifically, we would like to address the following issues with you:

• The need to re-assess the major goals for the instrument and engage with key stakeholder groups in a clear articulation of a unified vision and objectives for the MDS.

• The need to assess the current charge for the contract team engaged to work with CMS on this effort, in light of a clear consensus on vision and direction, as well as whether the resources devoted to this effort and the timeline for its completion are realistic.

• The need to coordinate this activity with the rapidly unfolding HHS efforts to facilitate improved information technology capacity and the widespread adoption of electronic health information systems.

We are very concerned that if these key issues are not addressed prior to finalizing major MDS 3.0 design decisions, the new instrument will fall short of its potential and lack stakeholder support. Given the investment of significant resources on the part of all concerned parties to make this transition, it would be most unfortunate if this historic opportunity to significantly improve the process were lost.

We are eager to meet with you prior to the planned August 25-26 meeting of the Technical Expert Panel that will be advising the contract team on their work. We would like to suggest a date sometime during the weeks of August 4th or 11th.

Please contact Ruta Kadonoff at (202) 508-9450, rkadonoff@aahsa.orgor, during the week of July 28-August 1, Evvie Munley at (202) 508 9478, emunley@aahsa.org, who will be happy to work with you or a member of your staff to coordinate a mutually convenient date and time. We look forward to your response.

Sincerely,

American Association of Homes and Services for the Aging
American Association of Nurse Assessment Coordinators
American Hospital Association
American Health Care Association
Catholic Health Association
National Association of Directors of Nursing Administration in Long-Term Care
National Association of Subacute and Post-Acute Care
National Citizens Coalition for Nursing Home Reform
National Hospice and Palliative Care Association

Cc: Tom Scully, CMS Administrator

May 21, 2004

Sean Tunis, MD
Chief Clinical Officer and Director, Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Tunis:

The undersigned organizations, representing key constituencies in the Resident Assessment Instrument (RAI) process, would like to express our continuing concerns about plans for development of the Minimum Data Set (MDS), version 3.0. We would appreciate the opportunity to meet with you and key staff working on this project as soon as possible.

As you are likely aware, we approached CMS in August of last year to voice our concerns with regard to the direction of the MDS 3.0 development process and to make recommendations on revising the project in order to better meet the needs of key stakeholders.

We appreciate the update that was provided on April 7th of this year, detailing CMS work since August, primarily on one of the key issues that was raised in our August meeting. We are pleased with the extensive efforts to better coordinate the MDS revision process with concurrent work on development of electronic medical records technology and standards. Ultimately, the seamless integration of the MDS with electronic medical records systems will greatly reduce the paperwork burden on professional nursing care staff and improve quality of care for residents as well as accurate information for CMS program objectives. CMS efforts to ensure that the next iteration of the MDS helps to begin moving providers in the direction of this ultimate goal are critical to fostering these evolving technologies and their diffusion in the long-term care setting.

We remain concerned, however, that other key issues that we raised in our August meeting do not seem to be figuring prominently in the current plans, as conveyed to us on April 7th.

We reiterate our firm belief that the MDS must be resident-focused and that the paramount objective in making revisions must be to improve the quality of information collected to facilitate accurate, comprehensive resident assessment and care planning, consistent with the law, current regulations, current standards of practice and the best available science on quality care for the populations served in nursing homes.

While keeping this goal primary in our minds, we must also strive to ensure that the critical information is being collected not only to support current quality measurement and payment needs, but also to ensure that revisions give us the capacity to improve and strengthen these systems in the future through the collection of better data that provides more robust information for these purposes.

In particular, the following three issues, which we raised with CMS last August, do not appear to be a part of the current work plans as we understand them.

• The vision, goals and objectives for the MDS must be clearly defined. Objectives must be prioritized, in order to ensure that decisions about items that are/are not to be included are based on a clear and rational set of criteria specifying how competing priorities are to be reconciled. The methodology that will be used for achieving and maintaining the clinical relevance of the MDS in accordance with evolving standards of care must also be defined.

• The current effort fails to take into account and prioritize all of the purposes that the MDS data are expected to serve. The first step in the process of re-design should be to pose open-ended questions about what information, if collected, could improve the instrument’s utility for one or more of its primary or secondary purposes -- assessment, care planning, quality measurement, payment, support of regulatory activities, and research.

• We must strive to improve the instrument’s ability to meet the needs of specific types of residents (e.g., long-term, post-acute, end-of-life/palliative care, non-elderly adults, pediatric) by targeting specific questions through the use of skip patterns or a modular approach to the form. The diverse residents in nursing homes are not well-served by a one-size-fits-all approach to assessment.

Finally, we would like to see CMS working in greater collaboration with key stakeholders. The time span between our initial meeting in August of 2003 and the first follow-up in April of 2004 concerns us, as does the latest communication we received from Bob Connolly. In his recent e-mail to our group, Connolly notes that an every-other-month or quarterly schedule of calls/meetings had been proposed by many of the stakeholders on the April 7th call. He went on to state that, “we likely won’t have much to report in the next 2-3 months,” and that CMS would not yet be scheduling another follow-up.

We urge CMS to engage more directly with our groups and other stakeholders as partners in this effort. We would appreciate being a part of design and planning efforts, with an opportunity to engage in dialogue and planning with CMS rather than merely reacting to reports on the work completed. We believe this would also be to CMS’ advantage, in that it would help to guide this effort in a direction that will be more likely to achieve the support and buy-in from the ultimate users and beneficiaries of this work, which will be critical to its acceptance.

We continue to be very concerned that if the key issues we have raised are not addressed prior to finalizing major decisions about the design of MDS 3.0, the new instrument will fall short of its potential and lack support. Given the investment of significant resources on the part of all concerned parties to make this transition, it would be most unfortunate if this historic opportunity to significantly improve the process were lost.

Accompanying this letter are our thoughts on proposed vision and mission statements for MDS, as well as a copy of the memo we provided at our August meeting, which summarizes our issues and makes specific recommendations as to how they might be addressed. We continue to believe that these recommendations outline critical steps that must take place prior to investment in field testing of an instrument. Key questions remain unaddressed in the process as we have seen it unfold to date -- what information do we need, about which residents, for what purposes? We need experts in clinical care, quality measurement and payment/resource utilization to come to consensus on answers to these questions first, then identify how each of the needed elements should ideally be collected -- via the MDS, via some other data collection tool (e.g., an independent, quality of life/satisfaction resident survey), or via electronic health records at a point when they are widely adopted.

We would appreciate the opportunity to meet with you as soon as possible to discuss these issues and develop plans for how they might be addressed. Please contact Ruta Kadonoff at (202) 508-9450, rkadonoff@aahsa.org, who will be happy to work with you or a member of your staff to coordinate a mutually convenient date and time. We look forward to your response.

Sincerely,

American Association of Homes and Services for the Aging
American Association of Nurse Assessment Coordinators
American Health Care Association
American Hospital Association
American Medical Directors Association
Catholic Health Association
National Association of Directors of Nursing Administration in Long-Term Care
National Citizens’ Coalition for Nursing Home Reform
National Hospice and Palliative Care Organization

Cc: Trent Haywood
Lisa Hines

References

Baker, L. (2000, April 27). Rehab Outcomes Stored at UB: Database Could Set the Standard for Medicare Reimbursement. University at Buffalo Reporter, 31(29). Accessed January 2008 at http://www.buffalo.edu/reporter/vol31/vol31n29/n2.html.

Berg, Katherine, et al. (2001). Identification and Evaluation of Existing Quality Indicators that are Appropriate for Use in Long-Term Care Settings. Final Report. Washington, DC: CMS. Accessed January 2008 at http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIYear2002Archives.zip.

Braddom, Randall L. (2005, July). “Medicare funding for inpatient rehabilitation: How did we get to this point and what do we do now?” Archives of Physical Medicine and Rehabilitation, 86(7): 1287-1292. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/16003652.

Buchanan, J.L., Andres, P.L., Haley, S.M., Paddock, S.M., & Zaslavsky, A.M. (2004). “Evaluating the planned substitution of the minimum data set-post acute care for use in the rehabilitation hospital prospective payment system.” Medical care, 42: 155-63. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/14734953.

Buchanan, J.L., Andres, P.L., Haley, S.M., Paddock, S.M., & Zaslavsky, A.M. (2003). “An assessment tool translation study.” Health Care Financing Review, 24: 45-60. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/12894634.

Continuity Assessment Record and Evaluation [CARE] Tool (2007, October 23). CMS-10243 [OMB#:0938-NEW]. Appendix A: Data Collection for Administering the Medicare Continuity Assessment Record and Evaluation (CARE) Instrument. Available for download from the CMS Paperwork Reduction Act web site at http://www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/itemdetail.asp?… or http://www.cms.hhs.gov/PaperworkReductionActof1995/downloads/CMS-10243.zip.

CARE Tool (2007, October 29). CMS-10243 [OMB#:0938-NEW]. Appendix B: Master Document (Core and Supplemental Items). Available for download from the CMS Paperwork Reduction Act web site at http://www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/itemdetail.asp?… or http://www.cms.hhs.gov/PaperworkReductionActof1995/downloads/CMS-10243.zip.

Carpenter, G.I. (2006). "Accuracy, validity and reliability in assessment and in evaluation of services for older people: The role of the interRAI MDS assessment system." Age and ageing, 35(4): 327-9. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/16788075.

Carter, G.M., Relles, D.A., Ridgeway, G.K., & Rimes, C.M. (2003l). "Measuring function for Medicare inpatient rehabilitation payment." Health Care Financing Review, 24(3): 25-44.

Carter, G.M., Relles, D.A. Wynn, B.O., et al. (2000). Interim Report on an InpatientRehabilitation Facility Prospective Payment System. Santa Monica, CA: RAND, MR-1503-CMS. Accessed at http://www.rand.org/pubs/drafts/DRU2309/.

Carter, G.M., Beeuwkes Buntin, M., Hayden, O., Kawata, J., Paddock, S.M., Relles, D.A., Ridgeway, G.K., Totten, M.E., & Wynn, B.O. (2001). Analyses for the Initial Implementation of the Inpatient Rehabilitation Facility Prospective Payment System. Santa Monica, CA: RAND, MR-1500-CMS. Accessed January 2008 at http://www.rand.org/pubs/monograph_reports/MR1500/.

Carter, J., et al. (2006). Making the “Minimum Data Set” Compliant with Health Information Technology Standards. Washington, DC: HHS Office of Disability, Aging and Long-Term Care Policy. Accessed January 2008 at http://aspe.hhs.gov/daltcp/reports/2006/MDS-HIT.htm.

CENDI Copyright Task Group (2002). Frequently Asked Questions About Copyright: Issues Affecting the U.S. Government. Oak Ridge, TN: CENDI Secretariat, Information International Associates, Inc. Accessed at http://www.cendi.gov/publications/04-8copyright.html#41.

Centers for Medicare & Medicaid Services [CMS] (2007, October 23). Data Collection for Administering the Medicare Continuity Assessment Record and Evaluation (CARE) Instrument. OMB Clearance Package Supporting Statement Part A.

CMS (2007, July 17). Data Collection for Administering the Medicare Continuity Assessment Record and Evaluation (CARE) Instrument. OMB Clearance Package Supporting Statement-Part A. Accessed January 2008 at http://www.cms.hhs.gov/PaperworkReductionActof1995/Downloads/CMS-10243.zip.

CMS (2006, July 31). Draft Minimum Data Set, Version 3.0 (MDS 3.0) For Nursing Home Resident and Care Screening. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS30Draft.pdf.

CMS. Home Health Quality Initiatives. Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/.

CMS. IRF Patient Assessment Instrument. Accessed January 2008 at http://www.cms.hhs.gov/InpatientRehabFacPPS/.

CMS. MDS 2.0 for Nursing Homes. Accessed January 2008 at http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp.

CMS. MDS 3.0 for Nursing Homes: Minimum Data Set (MDS) 3.0. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

CMS (2005, April). MDS 3.0 Update. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS30MDS30Update.pdf.

CMS. [MDS 3.0]: Phase 1 -- 2003 Stakeholder and Expert Review. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

CMS. [MDS 3.0]: Phase 2 -- VA Validation Protocol Research. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

CMS (2005, December 23). Medicare and Medicaid Programs: Reporting Outcome and ASsessment Information Set Data as Part of the Conditions of Participation for Home Health Agencies. Final Rule (70 FR 76199). Accessed at http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gp….

CMS (2007, August 29). Medicare Program; Home Health Prospective Payment System Refinement and Rate Update for Calendar Year 2008; Final Rule (72 FR 49761). Accessed at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gp….

CMS. Nursing Home Quality Initiatives: MDS 2.0 for Nursing Homes. Accessed January 2008 at http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp.

CMS. OASIS User Manual. Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp.

CMS. OASIS web site. Accessed December 2007 at http://www.cms.hhs.gov/OASIS.

CMS (2001, December 27). Privacy Act of 1974; Report of a Modified or Altered System (66 FR 66903). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2001_register&docid=01-31546-filed.

CMS (2002, December; revised March 2007). Revised Long-Term Care Facility Resident Assessment Instrument User's Manual. Version 2.0. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp.

CMS (2002, December; revised January 2008). Revised Long-Term Care Facility Resident Assessment Instrument User's Manual. Version 2.0. Accessed January 2008 at http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20RAIUsersManual.zip.

CMS (2008, January 24). Special Open Door Forum on Minimum Data Set 3.0 (MDS 3.0). Transcript accessed at http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp.

Choi, J., Jenkins, M.L., Cimino, J.J., White, T.M., & Bakken, S. (2005). “Toward semantic interoperability in home health care: Formally Representing OASIS items for integration into a concept-oriented terminology.”Journal of the American Medical Informatics Association, 12: 410-417. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15802480.

Code of Federal Regulations. Accessed at http://www.gpoaccess.gov/cfr/index.html.

Code of Federal Regulations. CFR 42 §484 Public Health. Chapter IV-Health Care Financing Administration, Department of Health and Human Services. Part 484 -- Conditions of Participation: Home Health Agencies. Accessed December 2007 at http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr484_06.html.

Connolly, Robert (2007, October). MDS 3.0 Implementation Plans. Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, CO.

Consolidated Health Informatics (2006). Standards Adoption Recommendation -- Functioning and Disability. Accessed at http://www.ncvhs.hhs.gov/061011p2b.pdf.

Cotterill, P.G., & Gage, B.J. (2002). “Overview: Medicare post-acute care since the Balanced Budget Act of 1997.” Health Care Financ Rev, 24: 1-6. Accessed January 2008 at http://www.cms.hhs.gov/HealthCareFinancingReview/Downloads/Winter_2002_Post_Acute_Care.zip.

Deficit Reduction Act of 2005. Public Law 109-171 (Section 5008). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ171.109.

Dellefield, M.E. (2007). “Implementation of the resident assessment instrument/minimum data set in the nursing home as organization: Implications for quality improvement in RN clinical assessment.” Geriatric Nursing, 28: 377-386. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/18068821.

Department of Health & Human Services (2007, December 17). Additional Consolidated Health Information (CHI) Health Information Technology Standards. 72 Federal Register71413-14. Accessed at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gp….

Dougherty, Michelle (2001). "Documentation in the Long Term Care Record," In Long Term Care Health Information Practice and Documentation Guidelines. Chicago, IL: Foundation of Research and Education of the American Health Information Management Association. Accessed January 2008 at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001235.hcsp.

Dougherty, Michelle, &, Mitchell, Sue (2004, November/December). "Getting better data from the MDS: Improving diagnostic data reporting in long-term care facilities." Journal of AHIMA, 75(10): 28-33. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15559836.

Federal Register. Access at http://www.gpoaccess.gov/fr/index.html.

Fiedler, Roger C., Granger, Carl V. & Russell, Carol F. (2000, March/April). “UDSMR^SM: Follow-up data on patients discharged in 1994-1996.” American Journal of Physical Medicine & Rehabilitation, 79(2): 184-192.PubMed link http://www.ncbi.nlm.nih.gov/pubmed/10744194.

Fries, Brant. Curriculum Vitae. Accessed January 2008 at http://www.sph.umich.edu/faculty/pdf/bfries.pdf.

Fries, B.E. (2005, July 22). Testimony: [Building Great Assessment Systems: Lessons from the interRAI Collaborative], Public Hearing, Reports and Testimony, National Commission for Quality Long-Term Care. Accessed at: http://www.qualitylongtermcarecommission.org/meetings/722PH/pdf/txstmtRQIfries07-18-05.pdf.

Fries, Brant E., Morris, John N., Bernabei, Roberto, Finne-Soveri, Harriet, & Hirdes, John (2007, July). “Rethinking the resident assessment protocols.”Journal of the American Geriatrics Society, 55(7): 1139-1140. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/17608893.

Fries, B.E., Simon, S.E., Morris, J.N., Flodstrom, C., & Bookstein, F.L. (2001). “Pain in U.S. nursing homes: Validating a pain scale for the minimum data set.” The Gerontologist, 41(2): 173-9. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/11327482.

Gage, B., & Green, J. (2006). “The State of the Art: Current CMS PAC Instruments.” In Uniform Patient Assessment for Post-Acute Care. Aurora, CO: Division of Health Care Policy and Research, University of Colorado at Denver, and Health Sciences Center. Accessed at http://www.bu.edu/hdr/documents/QualityPACFullReport.pdf.

General Accounting Office (2001, January). “Appendix II: Development and Testing of the OASIS Data Set." In Medicare Home Health Care: OASIS Data Use, Cost, and Privacy Implications. Washington, DC: General Accounting Office. Accessed at http://www.gao.gov/new.items/d01205.pdf.

Government Accountability Office (2005, April). Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities. Report to the Senate Committee on Finance and the House Committee on Ways and Means. Accessed at http://www.gao.gov/new.items/d05366.pdf.

Granger, Carl V. (2008). Quality and Outcome Measures for Rehabilitation Programs. eMedicine http://emedicine.medscape.com/article/317865-overview.

Granger, C.V. (2007, September 17). UDSMR Comment Letter re: CMS CARE Tool and PAC-PRD Demonstration.

Granger, C.V., Deutsch, A., Russell, C., Black, T., & Ottenbacher, K.J. (2007). „Modifications of the FIM^® instrument under the inpatient rehabilitation facility prospective payment system.” Am J Phys Med Rehabil. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/17873825.

Granger, C., et al. (2007). “Modifications of the FIM^® instrument under the inpatient rehabilitation facility prospective payment system.” Am J Phys Med Rehabil, 86(11): 883-892. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/17873825.

Hamilton, B.B., Granger, C.V., Sherwin, F.S., Zielezny, M., & Tashman, J.S. (1987). “A Uniform National Data System for Medical Rehabilitation.” In Rehabilitation Outcomes: Analysis and Measurement. Baltimore, MD: Brookes (pp. 137-47).

Harada, N.D., Kominski, G., & Sofaer, S. (1993). "Development of a resource-based classification for rehabilitation." Inquiry, 30(1): 54-63. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/8454315.

Harris, M., Chute, C.G., Harvell, J., et al. Toward a National Health Information Infrastructure: a Key Strategy for Improving Quality in Long-Term Care. Washington, DC: HHS Office of Disability, Aging and Long-Term Care Policy. Accessed at http://aspe.hhs.gov/daltcp/reports/toward.htm.

Harris, Y., & Clauser, S.B. (2002). “Achieving improvement through nursing home quality measurement.” Health Care Financ Rev, 23: 5-18. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/12500467.

Hawes, C., Mor, V., Phillips, C.D., Fries, B.E., Morris, J.N., Steele-Friedlob, E., et al. (1997). “The OBRA-87 nursing home regulations and implementation of the resident assessment instrument: Effects on process quality.” J Am Geriatr Soc, 45: 977-85. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/9256852.

Hawes, C., Morris, J.N., Phillips, C.D., Fries, B.E., Murphy, K., & Mor, V. (1997). “Development of the nursing home resident assessment instrument in the USA.” Age Ageing, 26: 19-25. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/9464550.

Health Care Financing Administration [HCFA] (1999, January 25). Medicare and Medicaid Programs: Reporting Outcome and ASsessment Information Set (OASIS) Data as Part of the Conditions of Participation for Home Health Agencies and Comprehensive Assessment and Use of the OASIS as Part of the Conditions of Participation for Home Health Agencies. Interim Final Rule with Comment (64 FR 3748-3763). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1999_register&docid=99-1448-filed.

HCFA (1999, January 25). Medicare and Medicaid Programs: Comprehensive Assessment and Use of the OASIS as Part of the Conditions of Participation for Home Health Agencies. Final Rule (64 FR 3764-3784). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1999_register&docid=99-1449-filed.

HCFA (1999, June 18). Medicare and Medicaid Programs: Mandatory Use, Collection, Encoding, and Transmission of Outcome and ASsessment Set (OASIS) for Home Health Agencies and Privacy Act of 1974; Report of New System; Notices (64 FR 32983). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1999_register&docid=99-15529-filed.

HCFA (1999, June 18). Privacy Act of 1974; Report of New System (64 FR 32992). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1999_register&docid=99-15530-filed.

Herndon, R.M. (2006). Handbook of Neurologic Rating Scales. New York, NY: Demos Medical Publishing. Google Books link http://books.google.com/books?id=w1yPmehSZ2cC&pg=PP1&dq=Handbook+of+Neurologic+Rating+Scales&sig=-Wq74yickQK8AsUDrddXMRbY7DE.

Hirdes, J.P. (2006). “Addressing the health needs of frail elderly people: Ontario's experience with an integrated health information system.” Age Ageing, 35: 329-331. Accessed at http://ageing.oxfordjournals.org/cgi/content/full/35/4/329.

Hirdes, Smith, Rabinowitz, Yamauchi, Pérez, Telegdi, et al. (2002). “The resident assessment instrument-mental health (RAI-MH): Inter-rater reliability and convergent validity.” Journal of Behavioral Health Services and Research, 29: 419-432. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/12404936.

Holthaus, Danielle, & Kramer, Andrew Kramer (2006). "Introduction, Background, and Objectives." In Uniform Patient Assessment for Post-Acute Care. Aurora, CO:Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006. Accessed at http://www.bu.edu/hdr/documents/QualityPACFullReport.pdf.

Ikegami, N., Hirdes, J.P., & Carpenter, I. (2002). “Measuring the Quality of Long-Term Care in Institutional and Community Settings.” In Measuring Up: Improving Health System Performance in OECD Countries. Paris: OECD (pp. 277-293). Accessed at http://www.ikwilwerken.nl/pdf/eu/8102011ehealthsystem.pdf.

Implementing the Resident Assessment Instrument: Case Studies of Policymaking for Long-Term Care in Eight Countries (2003, May). Milbank Memorial Fund Electronic Reports. Accessed at http://www.milbank.org/reports/interRAI/ResidentAssessment_Mech2.pdf.

Inouye S.K. (2003). The Confusion Assessment Method (CAM): Training Manual and Coding Guide. New Haven, CT: Yale University School of Medicine. Accessed at http://elderlife.med.yale.edu/pdf/The%20Confusion%20Assessment%20Method….

The Inpatient Rehabilitation Facility -- Patient Assessment Instrument (IRF-PAI) Training Manual: Effective 4/01/04 (2004). UB Foundation Activities, Inc. Accessed January 2008 at http://www.udsmr.org/pdfs/irfpaimanual040104%20(1).pdf.

Integrating the Healthcare Enterprise (IHE) wiki. Functional Status Assessments (FSA) Integration Profile Supplement. Accessed at http://wiki.ihe.net/index.php?title=Talk:Functional_Status_Assessments_(FSA)_Integration_Profile_Supplement.

interRAI web site. Accessed at http://www.interrai.org/.

interRAI. Licensing with interRAI. Accessed January 2008 at http://www.interrai.org/section/view/?fnode=32.

interRAI. Long Term Care Facility. Accessed January 15, 2008 at http://www.interrai.org/section/view/?fnode=17.

Jette, A.M., Haley, S.M., & Ni, P. (2003). “Comparison of functional status tools used in post-acute care.” Health Care Financ Rev, 24: 13-24. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/12894632.

Keillor, Ann, & Nutten, Sandra (1999). "Post-acute prospective payment: What you should know." Journal of AHIMA, 70(6): 24-30. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/10537621.

KPMG LLP (2006). University at Buffalo Foundation, Inc. and Affiliates Consolidated Financial Statements, June 30, 2006 and 2005. Accessed August 21, 2007 at http://www.ubfoundation.buffalo.edu/z/node/360.pdf.

Kramer, A. (2004). Case Studies of Electronic Health Records in Post-acute and Long-term Care. Washington, DC: HHS Office of Disability, Aging and Long-Term Care Policy. Accessed at http://aspe.hhs.gov/daltcp/reports/ehrpaltc.htm.

Liu, Korbin, Gage, Barbara, Harvell, Jennie, Stevenson, David, & Brennan, Niall (1999). Medicare's Post-Acute Care Benefit: Background, Trends, and Issues to be Faced Washington, DC: HHS Office of Disability, Aging and Long-Term Care Policy. Accessed at http://aspe.hhs.gov/daltcp/reports/1999/mpacb.htm.

LOINC. LOINC and RELMA Terms of Use. Accessed at http://www.regenstrief.org/medinformatics/loinc/terms-of-use.

Matherlee, K. (1999). “Implementing the BBA: The challenge of moving Medicare post-acute services to PPS.” Issue Brief Natl Health Policy Forum, 743: 1-8. Accessed at http://nhpf.ags.com/pdfs_ib/IB743_BBA_7-7-99.pdf.

Medicare Conditions of Participation. Access available through the Code of Federal Regulations at 42 CFR 482 (Hospital -- http://www.access.gpo.gov/nara/cfr/waisidx_07/42cfr482_07.html); 42 CFR 483 (Long Term Care -- http://www.access.gpo.gov/nara/cfr/waisidx_07/42cfr483_07.html); 42 CFR 484 (Home health -- http://www.access.gpo.gov/nara/cfr/waisidx_07/42cfr484_07.html); 42 CFR 412 (Inpatient Rehabilitation Facilities -- http://www.access.gpo.gov/nara/cfr/waisidx_07/42cfr412_07.html).

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999. Public Law 106-113 (Appendix F). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_cong_public_laws&docid=f:publ113.106.

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. Public Law 106-554 (Appendix F). Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_cong_public_laws&docid=f:publ554.106.

Medicare Payment Advisory Commission (2005). “Payment for Post-Acute Care.” In Report to the Congress: Issues in a Modernized Medicare Program. Washington, DC: MedPAC (pp. 103-133). Accessed at http://www.medpac.gov/publications/congressional_reports/June05_ch5.pdf.

Medicare Payment Advisory Commission (1999, March). "Post-Acute Care Providers: Moving Toward Prospective Payment." In Report to Congress: Medicare Payment Policy. Washington, DC: MedPAC (pp. 79-98). Accessed in http://www.medpac.gov/publications/congressional_reports/Mar99%20Ch5.pdf.

Mor, V. (2004). “A comprehensive clinical assessment tool to inform policy and practice: Applications of the minimum data set.” Medical Care, 42: 50-59. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15026672.

Morris, J.N., Hawes, C., Fries, B.E., Phillips, C.D., Mor, V., Katz, S., et al. (1990). “Designing the national resident assessment instrument for nursing homes.” The Gerontologist, 30: 293-307. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/2354790.

Murphy, Katharine M., & Morris, John N. (1995). “The resident assessment instrument: Implications for quality, reimbursement and research.” Generations, 19(4): 43-46.

National Library of Medicine [NLM] (2002). Appendix to the License Agreement for Use of the UMLS^®Metathesaurus. LNC_OASIS_2002 (new) -- The Outcome and ASsessment Information Set (OASIS). Denver, CO: Center for Health Services Research, UCHSC. Accessed at http://www.nlm.nih.gov/research/umls/metaa1.html.

NLM. UMLS web site. Accessed January 2008 at http://www.nlm.nih.gov/research/umls/.

Office of Management & Budget (1999). Circular A-110 (revised November 19, 1993; as further amended September 30, 1999). Accessed at http://www.whitehouse.gov/omb/circulars/a110/a110.html.

Ontario Joint Policy and Planning Committee (2002). Evaluation and Selection of a Classification/Assessment Tool for Rehabilitation Care in Ontario. Summary Report from the JPPC Rehabilitation Advisory Group. Accessed at http://www.jppc.org/new/files/acrobat/rd9_6.pdf.

Patent & Trademark Office web site. Accessed December 2007 at http://www.uspto.gov/.

RAND Health (2003, June 2,). "Evaluating Revisions to the Minimum Data Set for Nursing Homes." Presentation at CMS Town Hall Meeting on the MDS 3.0.

RAND Health (2008, January 24). "The MDS 3.0: Improving Assessment." Special Open Door Forum.

Reynolds, M. (2001). “Final inpatient rehabilitation PPS rule improves on proposed rule.” Healthc Financ Manage, 55: 68-70. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/11588870.

Shaughnessy, P.W., Crisler, K.S., Schlenker, R.E., & Arnold, A.G. (1997). "Outcomes across the care continuum: Home health care."Medical Care, 35(11): NS115-NS123. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/9424484.

Shaughnessy, Peter W., Crisler, Kathryn S., Schlenker, Robert E., & Hittle, David F. “Medicare’s OASIS: Standardized Outcome and ASsessment Information Set for Home Health Care -- July 1999.” In OASIS Implementation Manual 1/2008 Appendix B. Accessed at http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIOASISAppend….

Shaughnessy, Peter W., et al. (2002, March). Summary of the Report on OASIS and Outcome-Based Quality Improvement in Home Health Care: Research and Demonstration Findings, Policy Implications, and Considerations for Future Change. Denver, CO: Center for Health Services Research, University of Colorado Health Sciences Center. Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIOASISReportSummary.pdf.

Spector, W.D., & Drugovich, M.L. (1989). ”Reforming nursing home quality regulation: Impact on cited deficiencies and nursing home outcomes.” Medical Care, 27: 789-801. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/2755219.

Spector, William D., Potter, D.E.B., & De La Mare, Jan (2000, October). Future Directions for Residential Long-Term Care Health Services Research. Expert Meeting Summary. Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 01-0007. Accessed at http://www.ahrq.gov/research/futureltc/summary1.htm.

Stineman, M.G., Escarce, J.J., Goin, J.E., Hamilton, B.B., Granger, C.V., & Williams, S.V. (1994). “A case-mix classification system for medical rehabilitation.” Medical Care, 32: 366-379. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/8139301.

Stineman, M.G., Tassoni, C.J., Escarce, J.J., Goin, J.E., Granger, C.V., Fiedler, R.C., et al. (1997). “Development of function related groups version 2.0: A classification system for medical rehabilitation.” Health Services Research, 32: 529-548. PubMed Central link http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9327817.

Tesio, L., Granger, C.V., Perucca, L., Franchignoni, F.P., Battaglia, M.A., & Russell, C.F. (2002). “The FIM^®(TM) instrument in the United States and Italy: A comparative study.” Am J Phys Med Rehabil, 81: 168-176. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/11989512.

Trela, Patricia (2002). "Inpatient rehabilitation PPS presents new challenges, opportunities." Journal of AHIMA, 73(1): 48A-D. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/12469663.

Trela, Patricia (2007, May). "IRF PPS coding challenges."Journal of AHIMA, 78(5): 70-71. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/17552328.

Trosow, S.E. (2003). Copyright Protection for Federally Funded Research:Necessary Incentive or Double Subsidy?. Accessed at http://publish.uwo.ca/~strosow/Sabo_Bill_Paper.pdf.

UDSMR web site. Accessed January 2008 at http://www.udsmr.org/ and http://www.fimsystem.com/.

U.S. Copyright Office. Accessed December 2007 at http://www.copyright.gov/.

U.S. District Court, Western District of New York. "UB Foundation Activities, Inc., plaintiff v. IT Healthtrack, Inc. and Dr. Pamela Smith, Defendents." Docket report and filed documents. Case Filed June 14, 2004. Accessed December 2007 at http://pacer.psc.uscourts.gov.

University of Colorado, Center for Health Services and Policy Research. Right to Copy, Reprint, and Use Oasis. Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASISDataSetPermit.pdf.

University of Colorado, Center for Health Services Research, Division of Health Care Policy and Research. Accessed December 2007 at https://www2.uchsc.edu/chsr/index.shtml.

University of Michigan. U-M Researcher Leads Development of Health Care Standards (Press release). Accessed at http://www.umich.edu/news/index.html?Releases/2005/Apr05/r041805c.

Velozo, C.A., Byers, K.L., & Joseph, B.R. (2007). “Translating measures across the continuum of care: Using Rasch analysis to create a crosswalk between the Functional Independence Measure and the Minimum Data Set.”Journal of Rehabilitation Research and Development, 44(3): 467-478. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/18247243.

Wark, C.G., Insley, M.L., Tillery, L.S., & Orvis, N.J. (2004). “Government issue: CHI lays the groundwork for federal data exchange.” Journal of AHIMA/American Health Information Management Association, 75: 36-8. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15455567.

Wunderlich, Gooloo S., & Kohler, Peter O., eds. (2001). Improving the Quality of Long Term Care. Committee on Improving Quality in Long-Term Care, Division of Health Care Services, Institute of Medicine. Washington DC: National Academies Press. Accessed December 2007 at http://www.nap.edu/catalog.php?record_id=9611.

Endnotes

1. Wark, Cynthia G., et al. "Government Issue: CHI Lays the Groundwork for Federal Data Exchange." Journal of AHIMA 75, no.8 (September 2004): 36-38.

2. Consolidated Health Informatics (2006). Standards Adoption Recommendation -- Functioning and Disability. http://www.ncvhs.hhs.gov/061011p2b.pdf; NCVHS’s letter to the Secretary and Secretary Leavitt’s response are available on the NCVHS web site at http://www.ncvhs.hhs.gov/sssmemb.htm.

3. U.S. Department of Health and Human Services. "Additional Consolidated Health Information (CHI) Health Information Technology Standards" 72 Federal Register 71413-14 (December 17, 2007) Accessed January 2008 at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gp….

4. For purposes of this report, post-acute care services are defined as services received after patients are discharged from hospital stays to a skilled nursing facility (SNF), a home health agency (HHA), and/or a rehabilitation hospital/unit -- inpatient rehabilitation facility (IRF).

5. Kramer, Andrew, et al. Case Studies of Electronic Health Records in Post-Acute and Long-Term Care. Washington, DC: U.S. Dept. of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability and Long-Term Care Policy, 2004. http://aspe.hhs.gov/daltcp/reports/ehrpaltc.htm.

6. Kramer. Case Studies. (2004).

7. Gage, Barbara, and Jeremy Green. "The State of the Art: Current CMS PAC Instruments" Uniform Patient Assessment for Post-Acute Care (Aurora, CO: Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006), accessed at http://www.bu.edu/hdr/documents/QualityPACFullReport.pdf.

8. Wang, 2008.

9. 74 Federal Register 10050 (March 9, 2009) and 74 Federal Register 22208 (May 12, 2009).

10. 74 FR 10050 (March 9, 2009).

11. See http://www.nasl.org/files/members/IT/mds3-1-15-09.pdf.

12. National Association for Home Care and Hospice, AAHSA, AHIMA, CAST, National Association for the Support of Long Term Care. Response re: Information Collection -- Medicare and Medicaid Programs OASIS Collection Requirements as Part of the CoPs for HHAs and Supporting Regulations in 42 CFR, Sections 484.55, 484.205, 484.245, 484.250 [74FR10050] (April 8, 2009) accessed online at http://www.ahima.org/dc/documents/AHIMArespondstoOMBreviewrequestforCMS…. AHIMA. Comments on the Centers for Medicare & Medicaid Services’ (CMS) proposed changes to the Skilled Nursing Facilities Inpatient Prospective Payment Systems (SBF-PPS) as published in the May 12, 2009 Federal Register [74FR22208].

13. AHIMA. Comments on the Centers for Medicare & Medicaid Services’ (CMS) proposed changes to the Skilled Nursing Facilities Inpatient Prospective Payment Systems (SBF-PPS) as published in the May 12, 2009 Federal Register [74FR22208].

14. 74 Federal Register 40287 (August 11, 2009).

15. Chan, Leighton, Thomas D. Koepsell, Richard A. Deyo, Peter C. Esselman, Jodie K. Haselkorn, Joseph K. Lowery, and Walter C. Stolov. 1997. The Effect of Medicare's Payment System for Rehabilitation Hospitals on Length of Stay, Charges, and Total Payments. N Engl J Med 337, no. 14: 978-985. http://content.nejm.org/cgi/content/abstract/337/14/978.

16. Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, Pub.L. 106-113.

17. Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Pub.L. 106–554.

18. Deficit Reduction Act of 2005 (DRA 2005). Pub.L. 109-171.

19. Matherlee, Karen. "Implementing the BBA: the Challenge of Moving Medicare Post-Acute Services to PPS." National Health Policy Forum Issue Brief No.743 (Washington, DC: The George Washington University, 1999).

20. Pub.L. 106-554. Appx F -- Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. Section 545.

21. DRA 2005. Accessed at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ171.109.

22. U.S. Office of Management and Budget. "Data Collection for Administering the Medicare Continuity Assessment Record and Evaluation (CARE) Instrument" Clearance Package Supporting Statement Part A. (Washington, DC: Centers for Medicare and Medicaid Services, July 17, 2007).

23. Avalere Health LLC. (2009). Post-acute and Long-term Care Reform: Estimating the Federal Budgetary Effects of the AHCA/NCAL/Alliance Proposal. Retrieved July 16, 2009, from http://post-acute.org/bundling/Avalere%20Report%20prepared%20for%20AHCA-NCAL-Alliance%20on%20Post-acute%20and%20Long-term%20Care,%20April%202009.pdf.

24. Talk: Functional Status Assessments (FSA) Integration Profile Supplement (IHE wiki) accessed at http://wiki.ihe.net/index.php?title=Talk:Functional_Status_Assessments_(FSA)_Integration_Profile_Supplement.

25. Granger, Carl V. “UDSMR Comment Letter re: CMS CARE tool and PAC-PRD Demonstration”. (September 17, 2007).

26. Testimony of Brant E. Fries, Professor, Department of Health Management and Policy, University of Michigan School of Public Health, Public Hearing, Reports and Testimony, July 22, 2005. (Washington, DC: National Commission for Quality Long-Term Care) accessed at http://www.qualitylongtermcarecommission.org/meetings/722PH/pdf/txstmtRQIfries07-18-05.pdf.

27. U.S. Office of Management and Budget Circular A-110 (revised November 19, 1993; as further amended September 30, 1999), codified at 45 CFR §74.36 and 45 CFR §92.34 for the Department of Health and Human Service and 34 CFR §74.36 and 34 CFR §80.34 for the U.S. Department of Education, applies to grants awarded to nonprofit institutions; Federal Acquisition Regulation 52.227 (Rights in Data clauses begin with 227-14), codified at 48 C.F.R. §52.227-14-18 applies to data rights in the performance of contracts with federal agencies.

28. CENDI Copyright Task Group. Frequently Asked Questions About Copyright: Issues Affecting the U.S. Government. (Oak Ridge, TN: CENDI Secretariat, Information International Associates, Inc., 2002; updated August 2007) accessed at http://www.cendi.gov/publications/04-8copyright.html#41.

29. OMB Circular A-110 is codified at 45 CFR §74.36 and 45 CFR §92.34 for the Department of Health and Human Service and 34 CFR §74.36 and 34 CFR §80.34 for the U.S. Department of Education.

30. U.S. Office of Management and Budget. Circular A-110 (revised November 19, 1993; as further amended September 30, 1999) http://www.whitehouse.gov/omb/circulars/a110/a110.html#36l . Text from earlier versions of Circular A-110, in affect at the time of the contract or grant awards, is available in the relevant sections of the Code of Federal Regulations, referenced above. See also "The Federal Grant and Cooperative Agreement Act" (31 USC 6301-08), available at http://www.access.gpo.gov/uscode/title31/subtitlev_chapter63_.html for further guidance on the use of contracts, grants, and cooperative agreements.

31. Federal Acquisition Regulation. 48 CFR §27 (Patents, Data, and Copyrights). Solicitation provisions and contract clauses are addressed at 48 CFR §52.227-14 (Rights in Data -- General); §52.227-17 (Rights in Data -- Special Works); §52.227-18 (Rights in Data -- Existing Works).

32. FAR 52.227-17(c)(1).

33. Trosow, Samuel E.I. Copyright Protection for Federally Funded Research: Necessary Incentive or Double Subsidy? (draft paper September 7, 2003). Accessed at http://publish.uwo.ca/~strosow/Sabo_Bill_Paper.pdf.

34. 72 Federal Register 71413-14 (December 17, 2007).

35. U.S. Centers for Medicare & Medicaid Services (CMS). Data Collection for Administering the Medicare Continuity Assessment Record and Evaluation (CARE) Instrument. (OMB Clearance Package Supporting Statement Part A. (October 23, 2007).

36. U.S. Centers for Medicare & Medicaid Services (CMS). Revised Long-Term Care Facility Resident Assessment Instrument User’s Manual: version 2.0 (December 2002, revised March 2007).

37. CMS. RAI 2.0 User's Manual.

38. Wunderlich, G.S., & Kohler, P.O. “Information Systems for Monitoring Quality” Improving the Quality of Long-Term Care (Washington, DC: National Academies Press, 2001).

39. Information about RAVEN software is accessible at http://www.cms.hhs.gov/MinimumDataSets20/07_RAVENSoftware.asp.

40. Regulations are available on the Federal Register web site at http://www.gpoaccess.gov/fr/index.html. These regulations have been codified at 42 CFR 483.20 (Public Health, Requirements for States and Long Term Care Facilities, Resident Assessment). CFR 483.75 covers the confidentiality issues. Other relevant legislation affecting the MDS includes the Omnibus Budget Reconciliation Act of 1987. P.L. 100-203. Subtitle C: Nursing Home Reform. (OBRA 1987) and the Balanced Budget Act of 1997 (BBA 1997) (establishing the PPS system). Section 1819 of the Social Security Act contains the regulations for skilled nursing facilities participating in the Medicare program and section 1919 contains the regulations for nursing facilities participating in the Medicaid program. Annual updates to the prospective payment system (PPS) rates for skilled nursing facilities (SNFs) are required by section 1888(e) of the Social Security Act, added by section 4432 of the Balanced Budget Act of 1997 (BBA), and amended by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

41. Smith vs. O'Halloran, 55i F Supp. 289 (Denver, Colorado Circuit, in 1983.), reversed subnom. Smith vs, Heckler, i37 F2nd 583 (10th Cir 1984) see Spector, W.D., & Drugovich, M.L. (1989). "Reforming Nursing Home Quality Regulation: Impact on Cited Deficiencies and Nursing Home Outcomes." Medical Care, 27, 789-801.

42. Morris, J.N., Hawes, C., Fries, B.E., Phillips, C.D., Mor, V., Katz, S., et al. (1990). "Designing the national resident assessment instrument for nursing homes." The Gerontologist, 30, 293-307.

43. Institute of Medicine. Committee on Nursing Home Regulation. Improving the Quality of Care in Nursing Homes. (Washington, DC: National Academy Press, 1986).

44. Hawes, C., Mor, V., Phillips, C.D., Fries, B.E., Morris, J.N., Steele-Friedlob, E., et al. (1997). "The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality." J Am Geriatr Soc, 45, 977-85.

45. U.S. Centers for Medicare & Medicaid Services. "Minimum Data Set (MDS) 3.0 Timeline" accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS302010Imple….

46. Cotterill, P.G., & Gage, B.J. (2002). "Overview: Medicare post-acute care since the Balanced Budget Act of 1997." Health Care Financ Rev, 24, 1-6.

47. 63 FR 26252-26316 ( May 12, 1998).

48. "Development of Resident Assessment System and Data Base for Nursing Home Residents," Health Care Financing Administration (#500-88-0055); October 1988; 4 years, $3.5 million (extended to 6 years, $4.9 million) to Research Triangle Institute, with Brown University, Hebrew Rehabilitation Center for the Aging and The University of Michigan. See Fries, Brant. "Curriculum Vitae" Accessed January 2008 at http://www.sph.umich.edu/faculty/pdf/bfries.pdf.

49. Morris (1990).

50. "Revision of Resident Assessment Instrument (RAI) and Development of Resident Assessment Protocols (RAPs)," Centers for Medicare and Medicaid Systems (#500-94-0058); September 30, 1994; 6 years, $465,000 to Hebrew Rehabilitation Center for Aged; Principal Investigator: J. Morris; Co-Principal Investigator [Brant Fries]. Refine Version 2 and develop Version 3 of the National Nursing Home Resident Assessment Instrument, develop the RAI-PAC assessment instrument for post-acute care, and evaluate the nursing home population under age 65." See Fries, "Curriculum Vitae".

51. interRAI web site. "Long Term Care Facility". Accessed January 2008 at http://www.interrai.org/section/view/?fnode=17.

52. See Fries et al. letter to the editor, Journal of the American Geriatrics Society, July 2007.

53. The letter to the editor from Lisa Hines at the Office of Clinical Standards and Quality of the Health Care Financing Administration objected to the use by the authors, who were also investigators associated with contractors or subcontractors on the HCFA MDS contracts, of the designation "InterRAI-HCFA" in describing the work that was being done under contract to HCFA. The author of the letter wanted to make it clear that the contract was not with interRAI, and that whatever relationship the authors had with interRAI, their work on the contract had nothing to do with that relationship but due to the fact that they were experts in the field. Hines, L. (2001). Response to "Pain in U.S. nursing homes: validating a pain scale for the Minimum Data Set". The Gerontologist, 41(4), 553.

54. U.S. Centers for Medicare & Medicaid Services. MDS 3.0 Town Hall Meeting Conference Call. Transcript (June 3, 2003) Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

55. U.S. Centers for Medicare & Medicaid Services. [MDS 3.0]: Phase 1 -- 2003 Stakeholder and Expert Review. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

56. U.S. Centers for Medicare & Medicaid Services. Draft Minimum Data Set, Version 3.0 (MDS 3.0) For Nursing Home Resident and Care Screening. (July 31, 2006) http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS30Draft.pdf.

57. RAND Health. "The MDS 3.0: Improving Assessment." Special Open Door Forum, January 24, 2008.

58. U.S. CMS [MDS 3.0]: Phase 1 -- 2003 Stakeholder and Expert Review.

59. RAND Health. "Evaluating Revisions to the Minimum Data Set for Nursing Homes" Presentation at CMS Town Hall Meeting on the MDS 3.0 (June 2, 2003).

60. U.S. Centers for Medicare & Medicaid Services. [MDS 3.0]: Phase 2 -- VA Validation Protocol Research. Accessed at http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.

61. RAND Corporation. (April 2008). Development & Validation of a Revised Nursing Home Assessment Tool: MDS 3.0.

62. Dougherty, Michelle, and Sue Mitchell. "Getting Better Data from the MDS: Improving Diagnostic Data Reporting in Long-term Care Facilities." Journal of AHIMA 75, no.10 (Nov-Dec 2004): 28-33. PubMed link http://www.ncbi.nlm.nih.gov/pubmed/15559836.

63. Letter to Barbara Paul, MD, Director, Quality Measurement and Health Assessment Group at CMS. Signees were the American Association of Homes and Services for the Aging, the American Association of Nurse Assessment Coordinators, the American Hospital Association, the American Health Care Association, the Catholic Health Association, the National Association of Directors of Nursing Administration in Long-Term Care, the National Association of Subacute and Post-Acute Care, the National Citizens Coalition for Nursing Home Reform, and the National Hospice and Palliative Care Association.

64. Apelon Inc., Making MDS 3.0 Compliant with CHI Standards: Project Summary (August 2005). Accessed at http://aspe.hhs.gov/daltcp/reports/MDSprjsum.htm.

65. 72 Federal Register 71413-14 (December 17, 2007).

66. PPS Alert for Long-Term Care, May 2009, p.7.

67. 74 Federal Register 22208 (May 12, 2009).

68. MDS 3.0 RAI Manual (November 2009). http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS30RAIManual.zip.

69. See https://www.qtso.com/strive.html.

70. U.S. Centers for Medicare & Medicaid Services. "Special Open Door Forum on Minimum Data Set 3.0 (MDS 3.0)." Transcript, January 24, 2008. Accessed at http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp.

71. Connolly, Robert. "MDS 3.0 Implementation Plans." Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado (October 2007).

72. U.S. Centers for Medicare & Medicaid Services. "Nursing Home Quality Initiatives: MDS 2.0 for Nursing Homes" accessed January 2008 at http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp.

73. Morris, John N., Katharine Murphy, and Sue Nonemaker. Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual. (HCFA, October 1995).

74. U.S. Centers for Medicare & Medicaid Services. Revised Long-Term Care Facility Resident Assessment Instrument User's Manual: Version 2.0. (December 2002; revised March 2007).

75. Murphy, Katharine M., and John N. Morris. "The resident assessment instrument: Implications for quality, reimbursement and research." Generations, Winter95, Vol. 19 Issue 4, p43-46.

76. Testimony of Brant E. Fries, Professor, Department of Health Management and Policy, University of Michigan School of Public Health, Public Hearing, Reports and Testimony, July 22, 2005. (Washington, DC: National Commission for Quality Long-Term Care) accessed at http://www.qualitylongtermcarecommission.org/meetings/722PH/pdf/txstmtRQIfries07-18-05.pdf.

77. Implementing The Resident Assessment Instrument: Case Studies Of Policymaking For Long-Term Care In Eight Countries (New York: Milbank Memorial Fund, 2003). Accessed at http://www.milbank.org/reports/interRAI/030222interRAI.html.

78. interRAI. "Licensing with interRAI." Accessed January 2008 at http://www.interrai.org/section/view/?fnode=32.

79. interRAI. "Licensing".

80. interRAI. "Licensing".

81. Hirdes, John P. et al., “The Resident Assessment Instrument-Mental Health (RAI-MH): Inter-Rater Reliability and Convergent Validity” The Journal of Behavioral Health Services & Research 2002, 29(4), 419-432.

82. Fries, B. E. (2005, July 22). Testimony of Brant E. Fries, Professor, Department of Health Management and Policy, University of Michigan School of Public Health. Public Hearing, Reports and Testimony, National Commission for Quality Long-Term Care. Accessed at: http://www.qualitylongtermcarecommission.org/meetings/722PH/pdf/txstmtRQIfries07-18-05.pdf.

83. Hirdes, J. P. (2006). "Addressing the health needs of frail elderly people: Ontario's experience with an integrated health information system." Age Ageing, 35, 329-331.

84. Canadian Institute for Health Information. (2005) Resident Assessment Instrument (RAI) -- MDS 2.0^©and RAPs Canadian Version, Second Edition, March 2005. Ordering information available at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=bl_ccrs_29apr2005_e.

85. See http://www.kent.ac.uk/chss/interrai/develop/what_is_interrai.htm, http://www.interrai-au.org/authorisation.htm, and http://ageing.hku.hk/interrai/index.html.

86. Integrating the Healthcare Enterprise (IHE) wiki. "Follow-ups to 2/15 call from Tom White" http://wiki.ihe.net/index.php?title=Talk:Functional_Status_Assessments_(FSA)_Integration_Profile_Supplement#Follow-ups_to_2.2F15_call_from_Tom_White.

87. U.S. National Library of Medicine. National Institutes of Health. (2007) "License Agreement for Use of the UMLS^® Metathesaurus^®." Accessed January 2008 at http://wwwcf.nlm.nih.gov/umlslicense/snomed/license.cfm.

88. LOINC. "LOINC and RELMA Terms of Use." Accessed January 2008 at http://www.regenstrief.org/medinformatics/loinc/terms-of-use.

89. Copyright information concerning sources in the LOINC database is available from the full RELMA download available at http://www.regenstrief.org/medinformatics/loinc/downloads/files/loinc-and-relma-complete-download/gotoCopyrightedFile. In the loinccdb MS Access database, see the Source Organization table.

90. interRAI web site accessed at http://www.interrai.org/section/view/?fnode=32.

91. LTCQ, Inc. ["MDS Scales"] accessed January 2008 at http://www.ltcq.com/MDS%20Scales.pdf.

92. CMS. Open Door Forum, held December 9, 2009.

93. See http://elderlife.med.yale.edu/pdf/The%20Confusion%20Assessment%20Method….

94. See http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=369.

95. Personal communication between staff at the Regenstrief Institute and the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

96. U.S. Centers for Medicare and Medicaid Research. U.S. Department of Health and Human Services. "OASIS Background". Accessed December 2007 at http://www.cms.hhs.gov/OASIS/02_Background.asp.

97. Shaughnessy, P.W., Crisler, K.S., Schlenker, R.E., & Arnold, A.G. (1997). "Outcomes across the Care Continuum: Home Health Care" Medical Care, 35(11), NS115-NS123.

98. U.S. Centers for Medicare & Medicaid Services. "OASIS: HAVEN." Accessed at http://www.cms.hhs.gov/OASIS/045_HAVEN.asp.

99. U.S. Centers for Medicare & Medicaid Services. "Home Health Quality Initiatives." Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/.

100. Regulations published are available at the Federal Register web site: 64 FR 3748 (January 25, 1999), 64 FR 3764 (January 25, 1999), 64 FR 32983 (June 18, 1999), 64 FR 32992 (June 18, 1999), 66 FR 66903 (December 27, 2001), 70 FR 76199 (December 23, 2005), and 72 FR 49761 (August 29, 2007). Regulations have been codified at: CFR 42 §484 Public Health. Chapter IV-Health Care Financing Administration, Department of Health and Human Services. Part 484 -- Conditions of Participation: Home Health Agencies http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr484_06.html and CFR 42 §488 Public Health. Chapter IV-Health Care Financing Administration, Department of Health and Human Services. Part 488 -- Survey, Certification, and Enforcement Procedures. Sections relevant to OASIS include: CFR 42 §484.20 - Reporting OASIS Information; CFR 42 §484.11 -- Release of patient identifiable OASIS information; CFR 42 §484.55 -- Comprehensive Assessment of Patients, and CFR 42 §488.68 -- State agency responsibilities for OASIS collection and data base requirements. Other relevant legislation includes: the Social Security Act §1861(o) which required the establishment of a Home Health Prospective Payment System (HHPPS); the Social Security Act §1891(d) which required the Secretary of HHS to designate an assessment instrument for home health agencies to use; the Balanced Budget Act of 1997, which authorized the Secretary of HHS to require that home health agencies submit information for the purpose of implementing a prospective payment system (PPS) for HHAs, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which temporarily suspended the requirements in CFR §484.55 requiring comprehensive assessments for non-Medicare/non-Medicaid patients.

101. Center for Health Services Research. Division of Health Care Policy and Research. University of Colorado Health Sciences Center. Accessed December 2007 at https://www2.uchsc.edu/chsr/index.shtml.

102. "Home Health Quality Measures and Data Analysis". Contract # HHSM 500-2005-000181 T.O. #2. (Awarded September 2006).

103. U.S. Centers for Medicare & Medicaid Services. Outcome and ASsessment Information Set : OASIS-C Guidance Manual. September 2009. Accessed at http://www.cms.hhs.gov/homehealthqualityinits/14_hhqioasisusermanual.asp.

104. Center for Health Services and Policy Research. "Right to Copy, Reprint, and Use Oasis". Accessed December 2007 at http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASISDataSetPermit.pdf.

105. Appendix to the License Agreement for Use of the UMLS^®Metathesaurus LNC_OASIS_2002 (new) -- The Outcome and Assessment Information Set (OASIS), 2002, Center for Health Services Research, UCHSC, Denver, CO. Accessed at http://www.nlm.nih.gov/research/umls/metaa1.html.

106. LOINC. "LOINC and RELMA Terms of Use." Accessed January 2008 at http://www.regenstrief.org/medinformatics/loinc/terms-of-use.

107. Copyright information concerning sources in the LOINC database is available from the full RELMA download available at http://www.regenstrief.org/medinformatics/loinc/downloads/files/loinc-and-relma-complete-download/gotoCopyrightedFile. In the loinccdb MS Access database, see the Source Organization table.

108. U.S. Centers for Medicare & Medicaid Services. OASIS Data Set. Accessed February 2008 at http://www.cms.hhs.gov/HomeHealthQualityInits/12_HHQIOASISDataSet.asp.

109. "Comprehensive Adult Nursing Assessment Including SOC/ROC Elements with CMS 485 Information" (Briggs Medical Service Company, 2003). Accessed December 2007 at http://shop.briggscorp.com/pdf/3491P.pdf.

110. Carter, G.M., & et al. (2002). Analyses for the Initial Implementation of the Inpatient Rehabilitation Facility Prospective Payment System. Retrieved from http://www.rand.org/pubs/monograph_reports/MR1500/.

111. "Item-by-Item IRF-PAI Coding Instructions" The Inpatient Rehabilitation Facility -- Patient Assessment Instrument (IRF-PAI) Training Manual: Effective 4/01/04. (Buffalo, NY: UB Foundation Activities, Inc., 2004), p. II-1. Accessed February 2008 at http://www.udsmr.org/pdfs/irfpaimanual040104%20(1).pdf.

112. Regulatory notices can be found at "Medicare Program; Prospective Payment System for Inpatient Rehabilitation Facilities; Proposed Rule" 65 FR 66303-66442 (November 3, 2000) and "Medicare Program; Prospective Payment System for Inpatient Rehabilitation Facilities; Final Rule" 66 FR 41316-430. Updates to the Medicare Conditions of Participation for Inpatient Rehabilitation Facilities have been codified at 42 CFR, sections 412.610, 412.614 and 412.602. In order to participate in the Medicare program, hospitals must comply with Medicare Conditions of Participation, which are found at CFR 42 482 and subparts. Before performing an assessment using the IRF-PAI, a patient must be given several documents outlining their privacy rights, based on the Privacy Act of 1974 and HIPAA (1996).

113. 66 FR 41317 (August 7, 2001).

114. U.S. Centers for Medicare & Medicaid Services. (2002) IRF-PAI Training Manual. "Appendix J: Relative Weights for Case-Mix Groups (CMGs)".

115. A list of qualifying conditions is available at http://www.cms.hhs.gov/InpatientRehabFacPPS/Downloads/IRF_PPS_75_percent_Rule_060807.pdf. This requirement has been one of the most controversial aspects of the IRF PPS. Implementation of the 75 percent rule was delayed several times and is being gradually phased in. For the last extension of the phase-in period for the 75 percent rule, see 44292 FR 72 (August 7, 2001) accessable at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gp….

116. 66 FR 41323 (August 7, 2001).

117. 66 FR 41326 (August 7, 2001).

118. 66 FR 41325 (August 7, 2001).

119. 66 FR 56681-56687.

120. Trela, Patricia. "IRF PPS Coding Challenges." Journal of AHIMA 78, no.5 (May 2007): 70-71.

121. ACRM/AAPM&R Task Force, Uniform National Data System, Meeting Minutes (Las Vegas, NV, February 26, 1984).

122. Hamilton BB, Granger CV, Sherwin FS, Zielezny M, Tashman JS. "A uniform national data system for medical rehabilitation," in Fuhrer MJ (ed): Rehabilitation Outcomes: Analysis and Measurement. Baltimore, MD: Paul H Brookes Publishers, 1987, pp 137-147.

123. The Research Foundation of State University of New York, SUNY at Buffalo. "Proposal for Field Initiated Research Project: Development of a Uniform National Data System for Medical Rehabilitation." Submitted to the National Institute of Handicapped Research, Office of the Assistant Secretary for Special Education and Rehabilitative Services, U.S. Department of Education by the State University of New York at Buffalo, Department of Rehabilitation Medicine, Carl V. Granger, M.D., Project Director, Byron B. Hamilton, M.D., Principal Investigator. (May 21, 1984).

124. ACRM/AAPM&R Task Force, Uniform National Data System, Meeting Minutes (Las Vega, NV, February 26, 1984).

125. A letter from Carl Granger to the American Hospital Association Section for Rehabilitation Hospitals and Programs suggesting how to respond to developers of existing assessment instruments included the text: "Several developers of disability assessment and rehabilitation outcome instruments and/or reporting systems have recommended that the Task Force adopt their products as a national system. The Task Force has noted the recommendations and implications of these requests and as a result has developed a position statement (appended) intended for wide dissemination concerning proprietary interests and development of the National Data System for Medical Rehabilitation…. The Task Force is attempting to anticipate the needs of the marketplace by developing an unbiased, valid, and reliable minimum data set." [Letter from Forer and Granger, signed only by Granger; no copy of the position statement found.] The Task Force rejected a system in place at the University of Pittsburgh, saying "Although the HUP system is perhaps the best available patient data base for medical rehabilitation, it has some shortcomings. It is an abstracting service with the usual reports to each hospital, but many rehabilitation units do not want to subscribe to such a service even if they are willing to contribute data for the purpose of establishing national norms." (Research Foundation, SUNY-Buffalo. "Proposal," 1984.)

126. The National Task Force on a Uniform National Data System for Medical Rehabilitation, Minutes September 28-29, 1985, Kansas City, MO.

127. The National Task Force on a Uniform National Data System for Medical Rehabilitation, Minutes for Meeting held in Baltimore, MD, October 20, 1986.

128. Research Foundation, SUNY-Buffalo. "Proposal," 1984.

129. The dispute over FIM ownership is at the heart of the FIM trademark case, in which UBFA, Inc. is the claimant and AMRPA the opposer. AMRPA argues in their opposition: “Applicant is aware that others in the field contributed to the research and development of the assessment tool known as the FIM, and that the assessment tool was not developed solely by or for Applicant but was the product of an industry-wide Task Force.” ("Notice of Opposition" American Medical Rehabilitation Providers Association, Opposer v UB Foundation Activities, Inc., Applicant" In The United States Patent and Trademark Office Before the Trademark Trial and Appeal Board, November 7, 2003). The UBFA applicant-respondent's trial brief (September 21, 2007) reads: "Dr. Carl Granger, the Director of Uniform Data System for Medical Rehabilitation ("UDS" or UDSMR") and a physician with an extensive background and experience in rehabilitation medicine, began to develop a medical-rehabilitation-assessment tool in 1970. In early 1984, Dr. Granger became a member of a task force to look at rehabilitation tools. Three months later, in May 1984, the Research Foundation of the State University of New York applied for a grant to the National Institute of Handicapped Research within the U.S. Department of Education. The grant's purpose was to develop a uniform national-data system for medical rehabilitation. Dr. Granger was the grant's Project Director. Contrary to repeated statements in AMRPA's Brief, the Task Force did not apply for or receive the grant; indeed the Task Force is explicitly identified in the grant application as nothing more than a consultant. As Dr. Granger testified, the Task Force played an advisory role. In 1985, the Research Foundation of the State University of New York filed a further application to continue the grant. The FIM^TM instrument was developed as part of the work under the grant; it was not completed before the grant was completed. All rights in the FIM^TM instrument were owned by the Research Foundation of the State University of New York, and were assigned to University at Buffalo Foundation Activities, Inc." ("Applicant-Respondent's Trial Brief" American Medical Rehabilitation Providers Association, Opposer-Petitioner, v UB Foundation Activities, Inc., Applicant-Respondent" The United States Patent and Trademark Office Before the Trademark Trial and Appeal Board, September 21, 2007).

130. ACRM/AAPM&R Task Force minutes (February 26, 1984).

131. American Medical Rehabilitation Providers Association, Opposer-Petitioner, v UB Foundation Activities, Inc., Applicant-Respondent" The United States Patent and Trademark Office Before the Trademark Trial and Appeal Board.

132. The grant extension proposal also suggested a greater role for the task force: "The AAPM&R Task Force reviewed a draft of the demographic characteristics and functional behavior items at the October 20 meeting held in conjunction with the annual meeting in Boston… Over the course of a full day's deliberations, decisions were made with respect to the items. A major decision was to measure functional behavior on a four-point rather than a five-point scale. The instrument is called the Functional Independence Measure." "Steven Forer [task force co-chair] developed the demographic items for review by the project personnel as well as a code sheet. Both were adopted with some modifications." ("Continuation of Field Initiated Research Project; Development of a Uniform National Data System for Medical Rehabilitation". Submitted to: The National Institute of Handicapped Research, Office of the Assistant Secretary for Special Education and Rehabilitation Services. Submitted by: The State University of New York at Buffalo, Department of Rehabilitation Medicine, Carl V. Granger, MD, Project Director, Byron B. Hamilton, MD, Principal Investigator, January 18, 1985).

133. Research Foundation, SUNY-Buffalo. "Proposal," 1984.

134. Research Foundation, SUNY-Buffalo. "Continuation of Field Initiated Research Project," 1985.

135. Harada, N.D., G. Kominski, and S. Sofaer (1993). "Development of a Resource-Based Classification for Rehabilitation" Inquiry. 30(1): 54-63.

136. Stineman, M.G. et al. (1994) "A Case Mix Classification System for Medical Rehabilitation." Medical Care 32 (4):366-79.

137. Carter, G.M., D.A. Relles, B.O. Wynn, et al., (2000) Interim Report on an InpatientRehabilitation Facility Prospective Payment System, Santa Monica, CA: RAND, MR-1503-CMS. Accessed at http://www.rand.org/pubs/drafts/DRU2309/.

138. P.L. 106-113.

139. Medicare Payment Advisory Commission: Post-Acute Care Providers: Moving Toward Prospective Payment. Report to Congress: Medicare Payment Policy. Washington, DC. March 1999.

140. UDSMR. "Statement of Ownership of the FIM System." (n.d.) The Statement went on to read: "Any incorporation of portions of the Guide or other copyrighted works relating to the FIM System into other works, any modification of any such modified works by third parties, and any use of any such copyrighted works of the FIM service marks owned by UDSMR, without a license from UDSMR, is and remains improper and in violation of UDSMR's intellectual property rights."

141. Tesio L, Granger CV, Perucca L, Franchignoni FP, Battaglia MA, Russell CF: "The FIM(TM) instrument in the United States and Italy: A comparative study." Am J Phys Med Rehabil 2002;81:168-176.

142. Letter from Kathleen Wall, Partner HodgsonRuss Attorneys LLP (counsel to UDSMR) to Mr. John Shinn, President, PPS Plus Software (December 5, 2002). [interestingly, this letter goes on to say that there is no comparison to MDS and OASIS, because those two, unlike the FIM, are not proprietary.]

143. UDSMR. Center for Functional Assessment Research. "Research Policy: Use of Instruments" http://www.udsmr.org/instruments.php. [Note December 21, 2009: the research policy is no longer available on the UDSMR web site. A view of an archived edition of the policy is available here -- http://web.archive.org/web/20050930205127/http://www.udsmr.org/instruments.php.]

144. "UDSMR International: General Information".

145. UDSMR states that countries, including Italy, Sweden, Finland, Israel, and Japan have implemented parts of the FIM system under license and standards developed by UDSMR. (Tesio, "The FIM Instrument".)

146. License Agreement Letter between UDSMR and Integrated Voice Solutions, dated July 12, 1994.

147. The Inpatient Rehabilitation Facility -- Patient Assessment Instrument (IRF-PAI) Training Manual: Effective 4/01/04. (UB Foundation Activities, Inc. 2004). Accessed at http://www.udsmr.org/pdfs/irfpaimanual040104%20(1).pdf.

148. UB Foundation Activities, Inc. "Briefs on Merits for Defendant" before the Trademark Trial and Appeal Board, in the U.S. Patent and Trademark Office. (September 21, 2007); KPMG LLP. University at Buffalo Foundation, Inc. and Affiliates. Consolidated Financial Statements, June 30, 2009 and 2008 (With Independent Auditor's Report Theron). (October 30, 2009). Accessed at http://www.ubfoundation.buffalo.edu/drpl/node/456.

149. Tesio. "The FIM Instrument" (2002).

150. Fiedler, Roger C., Granger, Carl V. and Carol F. Russell. (2000) “UDSMR^SM: Follow-Up Data on Patients Discharged in 1994-1996” American Journal of Physical Medicine & Rehabilitation 79:2, March/April 2000, pp. 184-192.

151. 66 FR 41334; U.S. Centers for Medicare & Medicaid Services. "IRF Patient Assessment Instrument" accessed at http://www.cms.hhs.gov/InpatientRehabFacPPS/04_IRFPAI.asp#TopOfPage.

152. See http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/irfpaimanual040104.pdf.

153. UDSMR. "UDSMR International: General Information" accessed at http://www.udsmr.com/WebModules/International/int_About.aspx.

154. UB Foundation Activities, Inc. "Briefs on Merits for Defendant" before the Trademark Trial and Appeal Board, in the U.S. Patent and Trademark Office. (September 21, 2007) License Agreement between UBFA, Inc. and HCFA, dated September 21, 1995.

155. License Agreement between UBFA, Inc. and HCFA, dated September 21, 1995.

156. American Medical Rehabilitation Providers Association, Opposer-Petitioner, vs. UB Foundation Activities, Inc., Applicant-Respondent. "Applicant-Respondent's Trial Brief". Trademark Trial and Appeal Board, U.S. Patent and Trademark Office, deposited September 21, 2007. http://ttabvue.uspto.gov/ttabvue/ttabvue-91158512-OPP-70.pdf.

157. Letter from Richard T. Linn, Director, UDSMR, to Christy Schmidt, Executive Coordinator, Regulatory Reform Initiative, ASPE, dated April 17, 2002. ASPE apparently had put out a request for input to which AMRPA had responded.

158. Richard Linn letter, April 17, 2002.

159. The text of the OMB circular at the time of the FIM grants was slightly different from what it is currently, but basically states the same thing. As codifed in 34 CFR 74.145 (revised as of July 1, 1984), the text read: "Copyrights. (a) Works under grants. Unless otherwise provided by the terms of the grant, when copyrightable material is developed in the course of or under a grant, the grantee is free to copyright the material or permit others to do so… (c) ED rights. If any coyrightable material is developed in the course of or under an ED grant or subgrant, ED shall have a royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or otherwise use, and to authorize others to use, the work for Federal Government purposes."

160. "Addendum to September 21, 1995 License Agreement Between Uniform Data System for Medical Rehabilitation and Department of Health and Human Services, the Centers for Medicare & Medicaid Services, dated February 1, 2002.

161. 1995 License Agreement.

162. 2002 License Agreement Addendum.

163. UDSMR Position Statement Concerning HCFA/RAND Reports on the Development of a Prospective Payment System for Medical Rehabilitation (dated September 1997).

164. Trosow, Samuel E. I. Copyright Protection for Federally Funded Research: Necessary Incentive or Double Subsidy? (draft paper September 7, 2003).

165. U.S. Patent and Trademark Office. Trademark Trial and Appeal Board. American Medical Rehabilitation Providers Association v. UB Foundation Activities, Inc. September 23, 2008. Accessed at http://ttabvue.uspto.gov/ttabvue/ttabvue-91158512-OPP-78.pdf.

166. For example, Herndon, in the Handbook of Neurologic Rating Scales 2nd ed.(Demos Medical Publishing, 2006) indicates that the 7-point scale is under copyright, but later writes that "The FIM has become proprietary."

167. Holthaus, Danielle, and Andrew Kramer. "Introduction, Background, and Objectives" Uniform Patient Assessment for Post-Acute Care (Aurora, CO: Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006). Accessed at http://www.bu.edu/hdr/documents/QualityPACFullReport.pdf.

168. The National Task Force on a Uniform National Data System for Medical Rehabilitation, Minutes for Meeting held in Baltimore, MD, October 20, 1986.

169. UDSMR web site.

170. Research Foundation, SUNY-Buffalo. "Continuation of Field Initiated Research Project," 1985.

171. UDSMR. "Why Uniform Data Now?" (n.d.) Document appears to be a draft of a brochure.

172. Letter marked "Draft" from Carl V. Granger, M.D. to Carolyn Zollar (dated August 8, 1986). This letter was in response to a letter from Carolyn Zollar, General Counsel to the National Association of Rehabilitation Facilities (NARF), dated June 29, 1986.

173. Letter re: UDSMR/Formations in Health Care, Inc. dated August 16, 1994, from Tricia T. Semmelhack to Laura Dickinson Lee.

174. Letter from Kenneth W. Aitchison, President, Kessler Rehabilitation Corporation to Carl V. Granger, M.D., UDSMR, dated April 7, 1998. (A copy of the AMRPA position statement was not located.)

175. Letter from Carl V. Granger, Professor Rehabilitation Medicine, and Director, CFAR & UDSMR to Kenneth V. Aitchison, President, Kessler Rehabilitation Corporation, dated April 28, 1998.

176. Letter from Marisa Smith, Paralegal, UDSMR to Robert M. Rowe, Director of Information Services, InterLink Rehab Services, dated October 22, 1999.

177. Email response from Marisa Smith, Legal Services Supervisor at UDSMR to Dr. Michael Yoshida at the VA, dated April 08, 2002.

178. Velozo, C.A., Byers, K.L., & Joseph, B.R. (2007). Translating measures across the continuum of care: Using Rasch analysis to create a crosswalk between the Functional Independence Measure and the Minimum Data Set. Journal of Rehabilitation Research and Development. 44(3): 467-478.

179. The VA user's manual for the FIM is available at http://www.va.gov/vdl/documents/Clinical/Func_Indep_Meas/fim_user_manual.pdf.

180. Braddom, Randall L. "Medicare Funding for Inpatient Rehabilitation: How Did We Get to This Point and What Do We Do Now?" Archives of Physical Medicine and Rehabilitation Volume 86, Issue 7, July 2005, Pages 1287-1292.

181. 17 U.S.C. §105 http://www.copyright.gov/title17/92chap1.html#105.

182. AHIMA Comments on CMS SNF PPS for Skilled Nursing Facilities (June 30, 2009). http://www.ahima.org/dc/documents/AHIMACommentsonCMSSNFPPSforSkilledNur….

Notes

1. 72 Federal Register 71413-14 (December 17, 2007).

2. CENDI Copyright Task Group. (2002, updated 2007). Frequently Asked Questions About Copyright: Issues Affecting the U.S. Government. Oak Ridge, TN: CENDI Secretariat, Information International Associates, Inc. Retrieved from http://www.cendi.gov/publications/04-8copyright.html#40.

3. Morris, John N., Katharine Murphy, and Sue Nonemaker. Long Term Care Facility Resident Assessment Instrument (RAI) User’s Manual. (HCFA, October 1995).

4. U.S. Centers for Medicare & Medicaid Services. Revised Long-Term Care Facility Resident Assessment Instrument User’s Manual: Version 2.0. (December 2002; revised March 2007).

5. Retrieved from http://www.cms.hhs.gov/Nursinghomequalityinits/25_NHQIMDS30.asp.

6. Personal correspondence between Regenstrief and ASPE.

7. CMS. Supporting Statement for Paperwork Reduction Act Submission -- Part A -- revised Form #CMS-R-245 (OMB #0938-0760) -- OASIS C (3/4/2009).

8. Retrieved from http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIResponsesToPublicComments.pdf.

9. Retrieved from http://www.nlm.nih.gov/research/umls/sourcereleasedocs/2009AA/LNC_OASIS/ and http://www.nlm.nih.gov/research/umls/sourcereleasedocs/2009AA/LNC_MDS/.

10. The author is aware of the trademark status of FIM and understands that, according to UBFA guidelines (http://www.udsmr.org/Documents/Trademark-service%20mark.pdf), FIM should only be used as an adjective. For the purpose of this report, when FIM is used as a noun, it is used as an abbreviation for the Functional Independence Measure, similar to Graham et al. [including Carl Granger of UDS_MR^®] (2008), p.861. http://biomed.gerontologyjournals.org/cgi/reprint/63/8/860. When used as an adjective, its registered trademark status will be indicated.

11. UDS_MR^® and FIM^®are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. (http://www.udsmr.org/Documents/Trademark-service%20mark.pdf).

12. "A public use set of codes and names designed to facilitate in particular the electronic transmission and storing of clinical laboratory results.” http://www.openclinical.org/medTermLoinc.html.

13. "the HL7 Standards -- are essentially freely available and can be used for free. As such, there are no usage licenses required or license fees payable when using the HL7 Standards to implement interfaces.” http://www.hl7.com.au/FAW.htm#Licensing.

14. These providers continued to be paid based on amendments to the Social Security Act by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, and were referred to as TEFRA facilities.

15. Refer to http://www.kent.ac.uk/chss/interrai/develop/what_is_interrai.htm.

16. Refer to http://www.interrai-au.org/authorisation.htm.

17. Refer to http://ageing.hku.hk/interrai/index.html.

18. Refer to http://www.cms.hhs.gov/InpatientRehabFacPPS/06_Software.asp#TopOfPage.

Appendix C: Rosetta Stone Mapping Guidelines and Heuristics

1. Purpose

The purpose of this project is to:

1. Develop a Health Level Seven International (HL7) Clinical Document Architecture (CDA) framework for the federally mandated Minimum Data Set 3.0 (MDS3.0) for nursing homes. HL7 CDA Release 2 (CDA R2) is a document markup standard that specifies the structure and semantics of clinical documents for the purpose of electronic health information exchange. CDA provides a mechanism for incremental semantic interoperability. Application of this recognized standard to the MDS 3.0 and the home health Outcome and Assessment Information Set (OASIS-C) assessments will allow health care facilities to communicate assessment content in an interoperable, industry-standard format.

2. Map the federally mandated MDS3.0 and OASIS-C assessment instruments to the Systematized Nomenclature of Medicine -- Clinical Terms (SNOMED CT) and other health IT vocabularies.

3. Present the SNOMED CT mapped data in a format that supports:

   1. Inbound receipt of semantically interoperable EHR content applicable to completion of the MDS3.0 or OASIS-C; and
   2. Outbound movement of semantically interoperable assessment content to an HL7 CDA Questionnaire Assessment or Patient Summary Document using the adopted Continuity of Care Document (CCD) standard.

The MDS CDA Implementation Guide (IG): The HL7 Implementation Guide for CDA R2: CDA Framework for Questionnaire Assessments (Universal Realm) and CDA Representation of the Minimum Data Set Questionnaire Assessment (U.S. Realm), Draft Standard for Trial Use (DSTU), Release 1 was published April 2009. This Implementation Guide specifies a standard for electronic submission of CDA questionnaire assessments that allows health care facilities to communicate assessment documents in an interoperable, industry-standard format. While not yet published through HL7, a preliminary DSTU Update Release for this implementation guide, based on the CMS MDS3.0 data specifications v1.00.0, October 2009, has been created in conjunction with this study. All references in this heuristics document are to the Implementation Guide for CDA R2: CDA Framework for Questionnaire Assessments (Universal Realm) and CDA Representation of the Minimum Data Set Questionnaire Assessment (U.S. Realm) Draft Standard for Trial Use, Update Release 2 (hereafter referred to as the MDS CDA implementation guide (IG)). In the future, we expect this Guide to be further refined.

2. HL7 CDA Representation Of Questionnaire Assessments

HL7 created a preliminary DSTU update, the MDS CDA Implementation Guide, based on the CMS MDS3.0 data specifications v1.00.0, October 2009. The MDS CDA IG specifies a standard for electronic submission of CDA questionnaire assessments that allows healthcare facilities to communicate assessment documents in an interoperable, industry-standard format. The questionnaire assessments contain multiple questions with specific answers.

The MDS CDA IG defines both a required Model of Use (MoU) representation and an optional Model of Meaning (MoM) representation for each entry in the CDA Body. These models (described below) support both a faithful representation of the exact questions and answers on an assessment questionnaire and a semantically interoperable and reusable representation that encodes their meaning. In addition, the EHR system may have data to determine the answer to a particular form’s question. In such a case, the relevant EHR data can be optionally included in the questionnaire instance as a Supporting Observation(s).

Re-Use of MDS & OASIS Data Through Interoperable, Industry Standard Formats Model of Use (MoU): MDS and OASIS concepts are represented using LOINC codes that have been developed to convey each question and answer precisely as it was captured on the assessment instrument. Model of Meaning (MoM): MDS and OASIS concepts are represented using standard vocabulary (e.g., SNOMED CT) and formal CDA clinical statement modeling. Supporting EHR Observations: MDS and OASIS concepts are represented as standard vocabulary value sets that support re-use of EHR content relevant to assessment questions.

• Model of Use (MoU) is the representation of question/answer data precisely in the form in which it was captured in the application of origin (i.e., the assessment instrument). A set of Logical Object Identifiers Names and Codes (LOINC) codes have been developed to represent each question and coded answer on the assessment questionnaire.

  • This MoU will support queries of the type “Find all patients with a Response of X to Question Y on Form Z.”

  • See 1.13.1 -- Model of Use Base Pattern and 1.13.2 -- Model of Use Question and Answer Patterns for details on MoU representation in the MDS CDA IG.

• Model of Meaning (MoM) includes the representation of clinical data or concepts using standard vocabulary and formal CDA Refined Message Information Model (RMIM)-compliant clinical statement modeling. Some or all of the questions and responses on a form are amenable to partial or complete formal modeling using constructs provided by the HL7 Reference Information Model (RIM) coupled with standard terminologies. MoM representation is optional in this specification because many questions are not currently amenable to formal representation using standard terminologies.

  • This MoM will support queries of the type “Find all patients with Condition X, regardless of the form used to collect the data.”

  • See 1.13.3 -- Model of Meaning Representation for details on MoM representation in the MDS CDA IG.

• Supporting EHR Observations -- Existing electronic health record (EHR) data may be relevant to making the decision about how to answer a particular form's question. In such a case, the MDS CDA IG defines how to optionally include “supporting observations” in the questionnaire instance.

  • See 1.13.4 -- Supporting Observations for details on supporting EHR observation representation in the MDS CDA IG.

3. Rosetta Stone

The Rosetta Stone spreadsheet was designed as a tool to assist health IT vendors of long-term care EHR products in the transition to using LOINC, SNOMED CT and other standard vocabularies as the terminology of choice for the documentation and conveyance of MDS 3.0 (based on CMS MDS3.0 data specifications v1.01.0, December 2010) and OASIS-C (based on CMS OASIS-C data specifications v2.00, Revision 3, October 2009) assessment content. The use of these healthIT standards should be transparent to the end user and the assessment content they are accustomed to seeing would remain unchanged. However, the software application would be enhanced to map the assessment content to standard vocabularies to support interoperable exchange and reuse of the assessment content. The Rosetta Stone is a tool that can be used for various mapping scenarios:

CMS Data Specifications: Several updates to the CMS MDS3.0 Data Specifications were released over the course of this project. It was out of scope for this project to revise deliverables based on data specification updates released following completion of a tool. Such updates will need to be addressed in the future. MDS tools created for this study are based on the CMS data specifications as listed below: MDS CDA Implementation Guide Update Release 2: used CMS MDS3.0 data specifications v1.00.0, October 2009 MDS Rosetta Stone: used CMS MDS3.0 data specifications v1.01.0 December 2010 OASIS Rosetta Stone: used CMS OASIS-C data specifications v2.00, Revision 3, October 2009

1. Map from MDS3.0 or OASIS-C in CMS format to corresponding Model of Use LOINC representation: In this scenario, for each MDS3.0 or OASIS-C question and answer, there is a corresponding LOINC question and answer code, respectively. For MDS3.0 questions and answers, the CDA pattern to be used when communicating the assessment items in CDA format is also listed. For this scenario, see the Rosetta Stone "Model of Use" tab in the attached Excel spreadsheet.

2. Map from MDS3.0 or OASIS-C in CMS format to corresponding Model of Meaning representation: In this scenario, for each MDS3.0 question and answer mappable to a standard terminology, there is a corresponding semantically complete representation, based on a complete modeling of the question against the HL7 Reference Information Model, coupled with codes from a standard terminology such as SNOMED CT or code sets such as ICD-9-CM or CVX. For OASIS-C questions and answers, there is a corresponding code from a standard terminology such as SNOMED CT or code set such as CVX.

   MDS3.0 and OASIS-C data elements were also evaluated against other standard terminologies such as RxNorm. However, these other terminologies were not compatible with the data captured in these CMS standardized assessment instruments.

   For this scenario, see the Rosetta Stone “Model of Meaning” tab in the attached Excel spreadsheet for the semantic representation of MDS or OASIS questions and answers.

3. Map from EHR data element to MDS3.0 element to facilitate semi-automated population of assessments from EHR data: In this scenario, one uses the Rosetta Stone "Supporting EHR Observation" tab and corresponding Access database of "Value Set Members". Where a SNOMED-encoded finding, ICD-9-CM code or ICD-10-CM code in the EHR maps into one of the value sets, it suggests the presence of EHR data that could be used to help fill in the corresponding MDS question.

   Note: Under this scope of work, value sets were only created for MDS3.0 Section I (Active Diagnoses) data elements. Additional work is needed to identify value sets for OASIS-C data elements and data elements for other sections of the MDS3.0.

A separate “Rosetta Stone” has been created for the MDS3.0 and the OASIS-C assessment instruments. Each Rosetta Stone is a spreadsheet with an Overview describing the content of the spreadsheet, and separate tabs for Model of Use and Model of Meaning content. The Rosetta Stone for the MDS3.0 also has a “Supporting EHR Observations” tab for Section I (Active Diagnoses) value sets as described above.

4. Mapping Methodology

4.1. Model of Meaning (MoM) Tab -- Minimum Data Set 3.0/OASIS-C to SNOMED CT Mapping

The MDS3.0 and OASIS-C consist of individual sections containing a series of questions and corresponding answers. Each of the MDS3.0 and OASIS-C data elements contains a coding schema that links a document section to the questions and answers for that section.

General principles guiding the mapping of MDS3.0 and OASIS-C data elements to SNOMED CT include:

1. Data elements are mapped to active SNOMED CT concepts (SNOMED CT Concept Status code “0”).

2. The MoM tab reflects the best SNOMED CT Fully Specified name (FSN) or its proximal parent code.

3. The approach to mapping the OASIS and MDS content is at the level of the answered question, with a primary focus on showing how the completed form is to be represented.

4. A one-to-one SNOMED CT mapping is selected whenever possible

   EXAMPLE:
   MDS3.0 Data Element:	B0600-2 -- No speech -- absence of spoken words
   SNOMED CT Concept ID:	286371003
   SNOMED CT FSN:	Does not speak (finding)
   SNOMED CT Best Match on MoM tab:	286371003 -- Does not speak (finding)

5. If a one-to-one mapping is not available, the data element is mapped to the SNOMED CT proximal parent that includes all of the possible descendent data elements necessary to represent the MDS/OASIS concept.

   Some MDS/OASIS data elements embody more than one concept (e.g. MDS item I4500 (CVA, TIA, or stroke)). When a one-to-one mapping to SNOMED CT is not available, the data element is mapped to the SNOMED CT code that best represents all concepts embodied in the MDS/OASIS data element.

   EXAMPLE:
   MDS3.0 Data Element:	I4500 -- Cerebrovascular accident (CVA), TIA, or stroke)
   SNOMED CT Concept ID #1 -- “CVA”:	230690007	Child concept to “cerebro-vascular disease (disorder)”
   SNOMED CT FSN #1:	cerebrovascular accident (disorder)
   SNOMED CT Concept ID #2 -- “TIA”:	266257000	Child concept to “cerebro-vascular disease (disorder):
   SNOMED CT FSN #2:	transient ischemic attack (disorder)
   SNOMED CT Concept ID #3 -- “‘stroke”:	230690007	Child concept to “cerebro-vascular disease (disorder):
   SNOMED CT FSN #3:	cerebrovascular accident (disorder)
   SNOMED CT Best Match on MoM tab:	62914000 -- cerebrovascular disease (disorder)	“Cerebro-vascular disease (disorder)” -- parent concept for CVA and TIA

6. If no comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping, the “Comment” column reflects the reason the data element could not be mapped.

   MDS and OASIS items that are not mapped to SNOMED CT would be represented by LOINC codes found in the MoU tab.

7. Unique SNOMED CT codes SHALL be used for the question and associated answer(s).

   Representing the structure/content of an assessment item in SNOMED CT will require the use of one of the following coding techniques: Use of a single SNOMED CT code that fully represents the patient’s status in terms of the question/answer pair (see example in Section 4.1.1 “Rules for SNOMED CT Mapping Using an Assertion Pattern”), or Use of two SNOMED CT codes: a SNOMED CT code to represent the question and a SNOMED CT code to represent the patient’s performance as measured by the answer (see example below).

   EXAMPLE:
   MDS3.0 Data Element:	Question: J0400 (Res pain interview: frequency)
   SNOMED CT Concept ID:	364631005
   SNOMED CT FSN:	pattern of pain (observable entity)
   MDS3.0 Data Element:	Response: J0400-1 (Almost constantly)
   SNOMED CT Concept ID:	255238004
   SNOMED CT FSN:	continuous (qualifier value)
   MDS3.0 Data Element:	Response: J0400-2 (Frequently)
   SNOMED CT Concept ID:	70232002
   SNOMED CT FSN:	frequent (qualifier value)
   MDS3.0 Data Element:	Response: J0400-3 (Occasionally)
   SNOMED CT Concept ID:	84638005
   SNOMED CT FSN:	occasional (qualifier value)
   MDS3.0 Data Element:	Response: J0400-4 (Rarely)
   SNOMED CT Concept ID:	89292003
   SNOMED CT FSN:	rare (qualifier value)

8. The same SNOMED CT code MAY be used for more than one response to a question.

   EXAMPLE:
   MDS3.0 Data Element:	Question: B0700 (Makes self understood)
   SNOMED CT Concept ID:	288743004
   SNOMED CT FSN:	ability to make self understood (observable entity)
   MDS3.0 Data Element:	Response: B0700-0 (Understood)
   SNOMED CT Concept ID:	288746007
   SNOMED CT FSN:	does make self understood (finding)
   MDS3.0 Data Element:	Response: B0700-1 (Usually understood -- difficulty communicating some words or finishing thoughts but is able if prompted or given time)
   SNOMED CT Concept ID:	288748008
   SNOMED CT FSN:	difficulty making self understood (finding)
   MDS3.0 Data Element:	Response: B0700-2 (Sometimes understood -- ability is limited to making concrete requests)
   SNOMED CT Concept ID:	288748008
   SNOMED CT FSN:	difficulty making self understood (finding)
   MDS3.0 Data Element:	Response: B0700-3 (Rarely/never understood)
   SNOMED CT Concept ID:	288747003
   SNOMED CT FSN:	does not make self understood (finding)

9. SNOMED CT grouper concepts SHALL NOT be used to represent the answer to a question if possible

   EXAMPLE:
   OASIS-C Data Element:	Question: M1100_PTNT_LVG_STUTN (Patient Living Situation)
   SNOMED CT Concept ID:	224209007
   SNOMED CT FSN:	residence and accommodation circumstances (observable entity)
   OASIS-C Data Element:	Response: 1 (Patient Lives Alone -- Around the clock)	DO NOT code to SNOMED CT parent concept: 365508006 -- finding of residence and accommodation circumstances (finding). This is a grouper concept.
   SNOMED CT Concept ID:	105529008
   SNOMED CT FSN:	lives alone (finding)
   OASIS-C Data Element:	Response: 6 (Patient Lives with Other Person -- Around the clock)
   SNOMED CT Concept ID:	160724009
   SNOMED CT FSN:	independent housing, not alone (finding)
   OASIS-C Data Element:	Response: 11 (Patient Lives in Congregate Situation -- Around the clock)
   SNOMED CT Concept ID:	105530003
   SNOMED CT FSN:	living in residential institution (finding)

10. MDS3.0 or OASIS-C demographic data elements:

    • SHALL NOT be mapped to a SNOMED CT concept if they are mapped to a CDA Header element. For example:

      • MDS3.0 Data Elements: A0600A (Social Security Number)
             A0900 (Birthdate)

    • SHALL NOT be mapped to a SNOMED CT concept if the MDS CDA IG instructs that the data element be coded to another code sets. For example:

      • The MDS CDA IG recommends the use of HITSP-recognized HL7 administrative gender codes
      • The MDS CDA IG maps the MDS marital status responses to the HITSP-recognized HL7 marital status codes
      • The MDS CDA IG uses the Ethnicity pattern, modeled per HITSP recommendations, where observation/value is drawn from CDC Race and Ethnicity Code Set

    • SHALL NOT be mapped to SNOMED CT concept if there is no clear relevance/usefulness to other care providers/clinicians. For example:

      • MDS3.0 Data Element: A0310A (Type of assessment: OBRA)

Summary: SNOMED Representations in the Model of Meaning Tab

Available SNOMED representations for the MDS and OASIS are found column G (SNOMED CT code) and column H (SNOMED CT Fully Specified Name) of the Model of Meaning tab in the respective Rosetta Stones. These Rosetta Stones also identify the primary reason that an assessment item is not mapped to a SNOMED concept (see column G in the respective MoM tab). The following statements are used to indicate the reason a concept is not mapped to SNOMED CT.

• Concept Not Mapped --

  • This demographic/administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians
  • No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
  • Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination*
  • Negated/frequency/qualifier data elements is addressed through the vendor information model or in the CCD
  • Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT
  • Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping

*NOTE: This study did not undertake activities to post-coordinate complex, compound MDS data elements.

See Section 6 below for examples of MDS and OASIS data elements relevant to each of the “Concept Not Mapped” statements below.

4.1.1. MoM Tab -- Rules for SNOMED-CT Mapping of MDS3.0/OASIS-C Data Elements

A variety of question/answer formats are found in the MDS3.0 and OASIS-C assessment instruments. Two techniques were used in mapping SNOMED CT concepts for these various question/answer formats:

• Assertion Pattern
• Question/Answer Pattern

Assertion Pattern Typically, MDS and OASIS questions that are in a “yes/no” or “check all that apply format” are represented using an “assertion pattern”. In an assertion pattern, the question itself is not mapped to SNOMED CT, only the response is represented (e.g. “the resident is comatose”, “the resident does not use hearing aid”). The SNOMED CT hierarchies used for mapping “assertion patterns” differ slightly from the hierarchies used to map data elements in a “question/answer pattern”.

Rules for SNOMED CT Mapping Using an Assertion Pattern

For items with a CDA MoM representation of “assertion pattern” (typically questions in a “yes/no” or “check all that apply” format):

1. The question SHALL NOT be mapped to SNOMED-CT

2. The answers SHALL be mapped to the following SNOMED CT hierarchies:

   • Clinical Findings
   • Situation with Specific Context
   • Procedure

EXAMPLE #1 -- Assertion Pattern (yes/no question format):
1. MDS 3.0 Question B0100 "Comatose" Answer = "No" (B0100-0) -- 271591004 -- Fully conscious (finding) Answer = "Yes" (B0100-1) -- 371632003 -- Coma (disorder)

EXAMPLE #2 -- Assertion Pattern (check all that apply format):

MDS 3.0 Item B0900A (Staff asmt mental status: recall current season) -- 225033002 -- Memory recall finding (finding) MDS 3.0 Item B0900B (Staff asmt mental status: recall location of room) -- 165287001 -- Memory: present place known (finding) MDS 3.0 Item B0900C (Staff asmt mental status: recall staff names/faces) -- 285227006 -- Able to remember faces (finding) MDS 3.0 Item B0900D (Staff asmt mental status: recall in nursing home) -- 165287001 -- Memory: present place known (finding)

Question/Answer Pattern Typically, MDS and OASIS questions that are answered by means of a scale (e.g., 1=adequate, 2=slightly impaired) are represented using a “question/answer pattern”. Both the question and answer(s) are mapped to SNOMED CT. The SNOMED CT hierarchies that can be used for mapping questions in a “question/answer” pattern differ slightly from the hierarchies used to map answers in a “question/ answer” pattern.

Rules for SNOMED CT mapping using a Question/Answer Pattern

For items with a CDA MoM representation of “question/answer pattern” (typically questions that have some type of ‘scale’ for the response (i.e., 1=x, 2=y, etc.):

1. The question SHALL be mapped to the following SNOMED-CT hierarchies:

   • Observable Entity
   • Procedure

2. The answers MAY be mapped to the following SNOMED CT hierarchies:

   • Clinical Findings
   • Qualifier
   • Procedure
   • Situation with Specific Context

EXAMPLE:

1. MDS 3.0 Question B0200 "Hearing" -- 364019009 -- Ability to hear (observable entity) Answer = "Adequate" (B0200-0) -- 16233902 -- Hearing Normal (finding) Answer = "Minimal Difficulty" (B0200-1) -- 162340000 -- Hearing difficulty (finding) Answer = "Moderate Difficulty" (B0200-2) -- 425091001 -- Difficulty hearing normal speech tones (finding) Answer = "Highly Impaired" (B0200-3) -- 306972000 -- Unable to hear loud voice (finding)

4.2. EHR Observation Tab --- Minimum Data Set 3.0 to SNOMED CT, ICD-9-CM and ICD-10 Mappings

For this project, value sets containing a collection of ICD-9-CM, ICD-10-CM and SNOMED CT codes that could support a given MDS response have been identified for each item in MDS3.0 Section I (Active Diagnoses). For example, the ICD-9-CM value set for MDS item I0100 (Cancer) includes all codes in the range 140-239. The presence of an ICD-9-CM code within this range in the patient’s EHR could flag the user to assess if response I0100 should be marked on the MDS assessment.

For purposes of this project, SNOMED CT, ICD-9-CM and ICD-10 value sets have been developed for data elements in MDS 3.0 Section I (Active Diagnoses) only. Value sets have not been developed for data elements in other sections of the MDS 3.0 or for the OASIS-C.

1. General principles guiding the value set mapping for SNOMED CT include the following:

   • Value sets are developed at the question level only and are mapped to the following SNOMED CT hierarchies

     • Clinical finding
     • Situation with explicit context

   • The questions are equivalent to the assertion patterns or question/answers patterns in the Rosetta Stone Model of Meaning tab. The value set consist of variations of the Model of Meaning concepts.

   EXAMPLE:
   MDS 3.0 Data Element I3700 -- Arthritis (e.g., degenerative joint disease (DJD), osteoarthritis, and rheumatoid arthritis (RA) Association/Model of meaning: Arthropathy (disorder) Concept ID 399269003 Value Set: Osteoarthritis (disorder) 396275006      Arthritis (disorder) 3723001      Decedents of Arthropathy (disorder) CID 399269003 within SNOMED CT

2. The value set mapping for ICD-9-CM and ICD-10-CM identifies relevant codes for the specified conditions found in the 2011 releases of the classification systems.

4.2.1. EHR Observation Tab -- Rules Used for the Development of SNOMED CT Value Sets

The Model of Meaning concept has been imported to the International Health Terminology Standards Development Organization (IHTSDO) Workbench mapping tool with intentional definition rules used to select the appropriate children concept nodes that relate to the Model of Meaning. Those nodes have been extracted and placed into an Access database. The Access database links the MoM to the valueset_name by clicking on the name within the database. The value set consists of the MDS description, MDS code, SNOMED CT concept ID (CID), the Fully Specified Name (FSN) and a comment column.

MDS Section I value set rules used include:

• Select ALL concepts that are:

  • Descendents of XXXXX
         OR
  • Descendents of YYYYYY
         AND
  • NOT Descendents of ZZZZZZ

• Concepts come from the following hierarchies:

  • Clinical Findings
  • Situation with specific context

• Any “history of XX” OR “family history of XX” are excluded from the SNOMED CT situation of specific context hierarchy

5. Rosetta Stone Population

CAP-STS was responsible for entering only the SNOMED CT related concept mappings onto the Rosetta Stone and Value Set spreadsheets, including:

• Model of Meaning Tab (MDS Rosetta Stone) -- all items in MDS sections A - Q

  • Column G (SNOMED CT Code)
  • Column H (SNOMED CT FSN)

• Supporting EHR Observation Tab (MDS Rosetta Stone) -- MDS Section I (Active Diagnoses) items

  • Column F (SNOMED CT Value Set Name)
  • Column G (SNOMED CT Value Set File Name)

• MDS Section I Value Set database with its corresponding value set spreadsheets

• Model of Meaning Tab (OASIS Rosetta Stone) -- all OASIS items

  • Column G (SNOMED CT Code)
  • Column H (SNOMED CT FSN)

Preliminary SNOMED CT mappings were assigned by CAP-STS to each MDS3.0 and OASIS data element. The SNOMED mappings were then validated with an MDS/OASIS subject matter expert in an item-by-item review process. Any discrepancies were either resolved or referred to a semantic matching expert for additional guidance and final mapping resolution.

5.1. Ongoing Maintenance of SNOMED Mapping

Ongoing maintenance should be performed to keep the assessment mappings up to date with: (i) new releases of the standard terminologies, and (ii) new versions of assessment instruments. The table below shows the release schedules for SNOMED CT.

Terminology	Update Cycle	When	When
SNOMED CT	2 x yr	Jan	July

6. Comments Used For MDS Concepts Not Mappable To Snomed CT

For MDS/OASIS concepts that do not have an equivalent/proximal parent mapping to SNOMED CT, the following comments have been used in the Rosetta Stones (MoM tab, column G) to illustrate why the concept is not mappable.

Rosetta Stone Comment	Concept Not Mappable -- MDS Example	Concept Not Mappable -- OASIS Example
Concept Not Mapped (Reason #1) --This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/clinicians.	A0310A -- Type of assessment: OBRA	M0010_CCN CMS Certification Number
Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping.	H0400 -- Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)	M1055_PPV_RSN_NOT_RCVD_AGNCY Not indicated; patient does not meet age/condition guidelines for PPV
Concept Not Mapped (Reason #3) -- Data element is a complex expression that is not mappable to a single SNOMED CT concept and requires post coordination.*	K0100C -- Swallow disorder: cough/choke with meals/meds	M1100_PTNT_LVG_STUTN Patient Lives Alone - Around the clock M2040_PRIOR_MGMT_ORAL_MDCTN Prior Med Mgmt: Oral Medications
Concept Not Mapped (Reason #4) -- Negated/frequency/qualifier data elements addressed through the vendor information model or in the CCD.	G0400A -- No impairment	M1240_FRML_PAIN_ASMT No standardized assessment conducted
Concept Not Mapped (Reason #5) -- Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT.	P0100D -- Restraints used in bed: other	M1410_RESPTX_NONE Respiratory Treatments: None of the Above
Concept Not Mapped (Reason #6) -- Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping.	A1100B -- Preferred language	M1016_CHGREG_ICD1 Regimen Change in Past 14 Days: ICD Code 1
*NOTE: This study did not undertake activities to post-coordinate complex, compound MDS data elements.

7. Resources

CMS Minimum Data Set 3.0 (MDS3.0)		MDS3.0: Maintained by the Centers for Medicare and Medicaid Service (CMS) Updated as needed Data specifications can be accessed at http://www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp
CMS Outcome & Assessment Information Set (OASIS-C)		OASIS-C: Maintained by the Centers for Medicare and Medicaid Service (CMS) Updated as needed Data specifications can be accessed at http://www.cms.gov/OASIS/04_DataSpecifications.asp
Codes for Vaccine Administered (CVX)		CVX codes: Are maintained by CDC's National Center of Immunization and Respiratory Diseases (NCIRD) Are updated as needed Can be accessed at http://www2a.cdc.gov/nip/IIS/IISStandards/vaccines.asp?rpt=cvx
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)		ICD-9-CM codes: Are maintained by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services Are updated in October (yearly) and April (if needed) Can be accessed at http://www.cdc.gov/nchs/icd/icd9cm.htm
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)		ICD-10-CM codes: Are maintained by the National Center for Health Statistics (NCHS) Are not valid for any purpose or use until October 1, 2013 (effective date per HIPAA requirements) Can be accessed at http://www.cdc.gov/nchs/icd/icd10cm.htm
Logical Object Identifiers Names and Codes (LOINC)		LOINC codes: Are maintained by Regenstrief Institute, Inc. Are updated as needed Can be accessed through the Regenstrief LOINC Mapping Assistant (RELMA) at http://loinc.org/relma
Standardized Nomenclature of Medicine - Clinical Terms (SNOMED CT)		SNOMED CT codes: Are maintained by the International Health Terminology Standards Development Organisation (IHTSDO ) Are updated twice a year in January and July Can be accessed through a variety of free browsers listed by the Unified Medical Language System (UMLS) at http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html

Appendix D: Rosetta Stone MDS Spreadsheet and MDS Value Set of Diagnosis Concepts

Toolkit Overview of MDS3.0 Rosetta Stone

The Rosetta Stone spreadsheet was designed for the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) as a tool to assist long term care providers and clinicians in the transition to using Logical Object Identifiers Names and Codes (LOINC) and SNOMED CT as the terminology of choice for the documentation and conveyance of MDS 3.0 assessment content (based on CMS MDS3.0 data specifications v1.01.0, December 2010). The Rosetta Stone is a tool that can be used for various mapping scenarios:

1. Map from MDS3.0 in CMS format to corresponding Model of Use LOINC representation: In this scenario, one uses the Rosetta Stone "Model of Use" tab. For each MDS3.0 question and answer, there is a corresponding LOINC question and answer code. In addition, the CDA pattern to be used when communicating the assessment items in CDA format is also listed.

2. Map from MDS3.0 in CMS format to corresponding Model of Meaning representation: In this scenario, one uses the Rosetta Stone "Model of Meaning" tab. For each MDS3.0 question and answer, there is a corresponding semantically complete representation, based on a complete modeling of the question against the HL7 Reference Information Model, coupled with codes from a standard terminology such as SNOMED CT or code sets such as ICD-9-CM or CVX.

   MDS3.0 data elements were evaluated against other standard terminologies such as RxNorm however the terminologies were not compatible with the data captured in the CMS assessment instrument.

3. Map from EHR data element to MDS3.0 element to facilitate semi-automated population of assessments from EHR data: In this scenario, one uses the Rosetta Stone"Supporting EHR Observation" tab and corresponding Access database of "Value Set Members". Where a SNOMED-encoded finding, ICD-9-CM code, or ICD-10-CM code in the EHR maps into one of the value sets, it suggests the presence of EHR data that can be used to help fill in the corresponding MDS question. (Note: Value sets were only created for MDS3.0 Section I data elements in this work product. Data elements for other sections of the MDS3.0 were not mapped to value sets.)

Rosetta Stone Context*
Tab 1	Overview	This tab presents a description of the Rosetta Stone and its content.
Tab 2	Model of Use	Using the MDS3.0 section and question ID as the primary sort order, this tab presents MDS3.0 Extract questions and answers (based on the CMS MDS2.0 data specification v1.01.0, December 2010) and corresponding: LOINC representations and codes (provided by Indiana University of Regenstrief Institute, Inc.) CDA pattern per HL7 Implementation Guide for CDA Release 2, CDA Framework for Questionnaire Assessments and CDA Representation of the Minimum Data Set Questionnaire Assessment (hereafter referred to as the MDS CDA Implementation Guide) Content of this tab is listed below. Columns A - D: MDS3.0 question and answer ID numbers and descriptions based on CMS data specifications v1.01.0, December 2010 Column A = CMS Section IDs for each MDS3.0 section Column B = CMS Question ID for each MDS3.0 data item (This column is the primary sort order for the tab.) Column C = CMS Answer ID for each MDS3.0 data item Column D = CMS Description for each MDS3.0 data item Column E: Contains some general guidance related to data mapping. Columns F - H: Contain relevant CDA mapping information per the HL7 Implementation Guide for CDA Release 2, CDA Framework for Questionnaire Assessments and CDA Representation of the Minimum Data Set Questionnaire Assessment Column F = Contains the Model of Use Question/Answer pattern for each MDS3.0 item in accordance with the MDS CDA Implementation Guide Column G = Contains the data type for each MDS3.0 item in accordance with the MDS CDA Implementation Guide Column H = Contains the type of unit the MDS3.0 question requires if the data type is Physical Quantity (PQ) in accordance with the MDS CDA Implementation Guide Columns O - Q: Contain LOINC representation of MDS3.0 Extract data items. Column O = LOINC question code for each MDS3.0 data item Column P = LOINC answer code for each MDS3.0 data item Column Q = LOINC answer set object identifier (OID) for each MDS3.0 data item Note: LOINC codes were not assigned if the MDS CDA Implementation Guide required the data element be coded to another code sets (e.g. HL7 administrative codes for gender and marital status)
Tab 3	Model of Meaning	Using the MDS3.0 section and question ID as the primary sort order, this tab presents MDS3.0 questions and answers (based on the CMS MDS2.0 data specification v1.01.0, December 2010) and corresponding: SNOMED CT (version 20100731) representations and codes for semantically mappable MDS3.0 data items ICD-9-CM (October 1, 2010 update) codes for MDS3.0 Section I (Active Diagnoses) data items ICD-10-CM (2011 release) codes for MDS3.0 Section I (Active Diagnoses) data items CVX (September 30, 2010 update) codes for MDS3.0 vaccination data items   Content of this tab is listed below. Note: CAP SNOMED Terminology Solutions provided the SNOMED CT mapping of MDS3.0 data items. The American Health Information Management Association (AHIMA) provided the ICD-9-CM, ICD-10-CM, and CVX mapping of MDS3.0 data items. Columns A - D: MDS3.0 question and answer ID numbers and descriptions based on CMS data specifications v1.01.0, December 2010 Column A = CMS Section IDs for each MDS3.0 section Column B = CMS Question ID for each MDS3.0 data item (This column is the primary sort order for the tab.) Column C = CMS Answer ID for each MDS3.0 data item Column D = CMS Description for each MDS3.0 data item Column E: Contains some general guidance related to data mapping. Column F: Contains the pattern used for mapping the SNOMED CT representation of the MDS3.0 data items. SNOMED mapping was based on either an "assertion pattern" or "question & answer pattern". Columns G - H: Contain SNOMED CT representation of semantically mappable MDS3.0 data items Column G = SNOMED CT code for each mapped MDS3.0 data item Column H = SNOMED CT Fully Specified Name (FSN) for each assigned SNOMED code Column I: Contains ICD-9-CM codes for the MDS3.0 active diagnoses (selected from MDS3.0 Section I data items) Column J: Contains ICD-10-CM codes for the MDS3.0 active diagnoses (selected from MDS3.0 Section I data items) Column K: Contains CDC Race and Ethnicity Codes for the MDS3.0 race/ethnicity data items Column L: Contains Codes for Vaccines Administered (CVX) for the MDS3.0 vaccination data items
Tab 4	Supporting EHR Observation	Using the MDS3.0 section and question ID as the primary sort order, this tab presents MDS3.0 Section I questions and answers for Active Diagnoses (data items I0100 thru I8000 based on the CMS MDS3.0 data specification v1.01.0, December 2010) and corresponding: SNOMED CT (version 20100731) value set identifiers ICD-9-CM (October 1, 2010 update) value sets ICD-10-CM (2011 release) value sets Notes: CAP SNOMED Terminology Solutions provided the SNOMED CT value sets for the MDS3.0 Section I (Active Diagnoses) data items. The value set for each Section I data item, found in a separate file named MDS_Value_Set.zip, contains the CMS ID and description of the data item and the corresponding SNOMED CT concept ID (CID) and the Fully Specified Name (FSN) for the members of the value set. The American Health Information Management Association (AHIMA) provided the ICD-9-CM and ICD-10-CM value sets for the MDS3.0 Section I (Active Diagnoses) data items. Columns A - D: MDS3.0 question and answer ID numbers and descriptions based on CMS data specifications v1.01.0, December 2010 Column A = CMS Section ID Column B = CMS Question ID for each MDS3.0 Section I data item (This column is the primary sort order for the tab.) Column C = CMS Answer ID for each MDS3.0 Section I data item Column D = CMS Description for each MDS3.0 Section I data item Column E: Contains some general guidance related to data mapping. Columns F - G: Contain the identifiers for the SNOMED CT value sets compiled by CAP SNOMED Terminology Solutions Column F = Value Set ID for each Section I data item Column G = Value Set name for each Section I data item Column H: Contains the ICD-9-CM codes comprising the value set for each data item in MDS3.0 Section I (Active Diagnoses) Column I: Contains the ICD-10-CM codes comprising the value set for each data item in MDS3.0 Section I (Active Diagnoses)
Tabs correspond to Excel file available at http://aspe.hhs.gov/daltcp/reports/2011/StratEng-D1.xlsx.

Rosetta Stone Resources
CMS Minimum Data Set 3.0 (MDS3.0)	MDS3.0: Maintained by the Centers for Medicare and Medicaid Service (CMS) Updated as needed Data specifications can be accessed at http://www.cms.gov/NursingHomeQualityInits/30_NHQIMDS30TechnicalInformation.asp
Codes for Vaccine Administered (CVX)	CVX codes: Are maintained by CDC's National Center of Immunization and Respiratory Diseases (NCIRD) Are updated as needed Can be accessed at http://www2a.cdc.gov/nip/IIS/IISStandards/vaccines.asp?rpt=cvx
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)	ICD-9-CM codes: Are maintained by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services Are updated in October (yearly) and April (if needed) Can be accessed at http://www.cdc.gov/nchs/icd/icd9cm.htm
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)	ICD-10-CM codes: Are maintained by the National Center for Health Statistics (NCHS) Are not valid for any purpose or use until October 1, 2013 (effective date per HIPAA requirements) Can be accessed at http://www.cdc.gov/nchs/icd/icd10cm.htm
Logical Object Identifiers Names and Codes (LOINC)	LOINC codes: Are maintained by Regenstrief Institute, Inc. Are updated as needed Can be accessed through the Regenstrief LOINC Mapping Assistant (RELMA) at http://loinc.org/relma
Standardized Nomenclature of Medicine - Clinical Terms (SNOMED CT)	SNOMED CT codes: Are maintained by the International Health Terminology Standards Development Organisation (IHTSDO) Are updated twice a year in January and July Can be accessed through a variety of free browsers listed by the Unified Medical Language System (UMLS) at http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html

MDS3.0 Items Mapping -- Model Of Use

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
A			Identification Information
	A0100A		Facility National Provider Identifier (NPI)	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0100B		Facility CMS Certification Number (CCN)	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0100C		State provider number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0200		Type of provider		Typical pattern	CD		54582-2		1.3.6.1.4.1.12009.10.1.61
	A0200	1	Nursing home (SNF/NF)		Typical pattern	CD		54582-2	LA10882-1	1.3.6.1.4.1.12009.10.1.61
	A0200	2	Swing bed		Typical pattern	CD		54582-2	LA10883-9	1.3.6.1.4.1.12009.10.1.61
	A0310A		Type of assessment: OBRA		Typical pattern	CD		54583-0		1.3.6.1.4.1.12009.10.1.60
	A0310A	1	Admission assessment (required by day 14)		Typical pattern	CD		54583-0	LA10-4	1.3.6.1.4.1.12009.10.1.60
	A0310A	2	Quarterly review assessment		Typical pattern	CD		54583-0	LA15-3	1.3.6.1.4.1.12009.10.1.60
	A0310A	3	Annual assessment		Typical pattern	CD		54583-0	LA12-0	1.3.6.1.4.1.12009.10.1.60
	A0310A	4	Significant change in status assessment		Typical pattern	CD		54583-0	LA13-8	1.3.6.1.4.1.12009.10.1.60
	A0310A	5	Significant correction to prior comprehensive assessment		Typical pattern	CD		54583-0	LA10888-8	1.3.6.1.4.1.12009.10.1.60
	A0310A	6	Significant correction to prior quarterly assessment		Typical pattern	CD		54583-0	LA10889-6	1.3.6.1.4.1.12009.10.1.60
	A0310A	99	Not OBRA required assessment/tracking		Typical pattern	CD		54583-0	LA10893-8	1.3.6.1.4.1.12009.10.1.60
	A0310B		Type of assessment: PPS		Typical pattern	CD		54584-8		1.3.6.1.4.1.12009.10.1.59
	A0310B	1	5-day scheduled assessment		Typical pattern	CD		54584-8	LA10894-6	1.3.6.1.4.1.12009.10.1.59
	A0310B	2	14-day scheduled assessment		Typical pattern	CD		54584-8	LA10895-3	1.3.6.1.4.1.12009.10.1.59
	A0310B	3	30-day scheduled assessment		Typical pattern	CD		54584-8	LA10896-1	1.3.6.1.4.1.12009.10.1.59
	A0310B	4	60-day scheduled assessment		Typical pattern	CD		54584-8	LA10897-9	1.3.6.1.4.1.12009.10.1.59
	A0310B	5	90-day scheduled assessment		Typical pattern	CD		54584-8	LA10898-7	1.3.6.1.4.1.12009.10.1.59
	A0310B	6	Readmission/return assessment		Typical pattern	CD		54584-8	LA10899-5	1.3.6.1.4.1.12009.10.1.59
	A0310B	7	Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)		Typical pattern	CD		54584-8	LA10900-1	1.3.6.1.4.1.12009.10.1.59
	A0310B	99	Not a PPS assessment		Typical pattern	CD		54584-8	LA10903-5	1.3.6.1.4.1.12009.10.1.59
	A0310C		Type of assessment: OMRA		Typical pattern	CD		54585-5		1.3.6.1.4.1.12009.10.1.65
	A0310C	0	No		Typical pattern	CD		54585-5	LA32-8	1.3.6.1.4.1.12009.10.1.65
	A0310C	1	Start of therapy assessment		Typical pattern	CD		54585-5	LA12624-5	1.3.6.1.4.1.12009.10.1.65
	A0310C	2	End of therapy assessment		Typical pattern	CD		54585-5	LA12625-2	1.3.6.1.4.1.12009.10.1.65
	A0310C	3	Both Start and End of therapy assessment		Typical pattern	CD		54585-5	LA12626-0	1.3.6.1.4.1.12009.10.1.65
	A0310D		Swing bed clinical change assessment		Typical pattern	CD		58107-4		1.3.6.1.4.1.12009.10.1.62
	A0310D	0	No		Typical pattern	CD		58107-4	LA32-8	1.3.6.1.4.1.12009.10.1.62
	A0310D	1	Yes		Typical pattern	CD		58107-4	LA33-6	1.3.6.1.4.1.12009.10.1.62
	A0310E		First assessment since most recent entry		Typical pattern	CD		54587-1		1.3.6.1.4.1.12009.10.1.62
	A0310E	0	No		Typical pattern	CD		54587-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	A0310E	1	Yes		Typical pattern	CD		54587-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	A0310F		Entry/discharge reporting		Typical pattern	CD		58108-2		1.3.6.1.4.1.12009.10.1.66
	A0310F	1	Entry record		Typical pattern	CD		58108-2	LA12627-8	1.3.6.1.4.1.12009.10.1.66
	A0310F	10	Discharge assessment - return not anticipated		Typical pattern	CD		58108-2	LA12628-6	1.3.6.1.4.1.12009.10.1.66
	A0310F	11	Discharge assessment - return anticipated		Typical pattern	CD		58108-2	LA12629-4	1.3.6.1.4.1.12009.10.1.66
	A0310F	12	Death in facility record		Typical pattern	CD		58108-2	LA12630-2	1.3.6.1.4.1.12009.10.1.66
	A0310F	99	Not entry/discharge record		Typical pattern	CD		58108-2	LA12631-0	1.3.6.1.4.1.12009.10.1.66
	A0410		Submission requirement		Typical pattern	CD		54896-6		1.3.6.1.4.1.12009.10.1.23
	A0410	1	Neither federal nor state required submission		Typical pattern	CD		54896-6	LA10908-4	1.3.6.1.4.1.12009.10.1.23
	A0410	2	State but not federal required submission (FOR NURSING HOMES ONLY)		Typical pattern	CD		54896-6	LA10907-6	1.3.6.1.4.1.12009.10.1.23
	A0410	3	Federal required submission		Typical pattern	CD		54896-6	LA10906-8	1.3.6.1.4.1.12009.10.1.23
	A0500A		Resident first name	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0500B		Resident middle initial	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0500C		Resident last name	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0500D		Resident name suffix	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0600A		Social Security Number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0600B		Resident Medicare/railroad insurance number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0700		Resident Medicaid number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0800		Gender	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0800	1	Male	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0800	2	Female	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A0900		Birthdate	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1000A		Ethnicity: American Indian or Alaska Native		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1000B		Ethnicity: Asian		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1000C		Ethnicity: Black or African American		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1000D		Ethnicity: Hispanic or Latino		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1000E		Ethnicity: Native Hawaiian/Pacific Islander		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1000F		Ethnicity: White		Ethnicity pattern	CD				2.16.840.1.113883.1.11.15836
	A1100A		Does the resident need or want an interpreter		Typical pattern	CD		54588-9		1.3.6.1.4.1.12009.10.1.58
	A1100A	0	No		Typical pattern	CD		54588-9	LA32-8	1.3.6.1.4.1.12009.10.1.58
	A1100A	1	Yes		Typical pattern	CD		54588-9	LA33-6	1.3.6.1.4.1.12009.10.1.58
	A1100A	9	Unable to determine		Typical pattern	CD		54588-9	LA11137-9	1.3.6.1.4.1.12009.10.1.58
	A1100B		Preferred language		Other response data type pattern	ED		54899-0
	A1200		Marital status	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1200	1	Never married	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1200	2	Married	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1200	3	Widowed	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1200	4	Separated	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1200	5	Divorced	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1300A	MDCL_REC_NUM	Medical record number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1300B	ROOM_NUM	Room number	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1300C	PREFRD_NAME	Name by which resident prefers to be addressed	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1300D		Lifetime occupation(s)		Other response data type pattern	ED		45418-1
	A1500		Resident evaluated by PASRR		Typical pattern	CD		54589-7		1.3.6.1.4.1.12009.10.1.57
	A1500	0	No		Typical pattern	CD		54589-7	LA32-8	1.3.6.1.4.1.12009.10.1.57
	A1500	1	Yes		Typical pattern	CD		54589-7	LA33-6	1.3.6.1.4.1.12009.10.1.57
	A1500	9	Not a Medicaid certified unit		Typical pattern	CD		54589-7	LA10921-7	1.3.6.1.4.1.12009.10.1.57
	A1550A		MR/DD status: Down syndrome		Multiple response pattern	BL		45422-3
	A1550B		MR/DD status: Autism		Multiple response pattern	BL		45423-1
	A1550C		MR/DD status: Epilepsy		Multiple response pattern	BL		45424-9
	A1550D		MR/DD status: other organic MR/DD condition		Multiple response pattern	BL		45425-6
	A1550E		MR/DD status: MR/DD with no organic condition		Multiple response pattern	BL		45426-4
	A1550Z		MR/DD status: none of the above		Multiple response pattern	BL		45421-5
	A1600		Entry date (date of admission/reentry in facility)	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A1700		Type of entry		Typical pattern	CD		54590-5		1.3.6.1.4.1.12009.10.1.56
	A1700	1	Admission		Typical pattern	CD		54590-5	LA10922-5	1.3.6.1.4.1.12009.10.1.56
	A1700	2	Reentry		Typical pattern	CD		54590-5	LA54-2	1.3.6.1.4.1.12009.10.1.56
	A1800		Entered from		Typical pattern	CD		54591-3		1.3.6.1.4.1.12009.10.1.55
	A1800	1	Community (private home/apt., board/ care, assisted living, group home)		Typical pattern	CD		54591-3	LA10924-1	1.3.6.1.4.1.12009.10.1.55
	A1800	2	Another nursing home or swing bed		Typical pattern	CD		54591-3	LA10925-8	1.3.6.1.4.1.12009.10.1.55
	A1800	3	Acute hospital		Typical pattern	CD		54591-3	LA9928-8	1.3.6.1.4.1.12009.10.1.55
	A1800	4	Psychiatric hospital		Typical pattern	CD		54591-3	LA10064-6	1.3.6.1.4.1.12009.10.1.55
	A1800	5	Inpatient rehabilitation facility		Typical pattern	CD		54591-3	LA10928-2	1.3.6.1.4.1.12009.10.1.55
	A1800	6	MR/DD facility		Typical pattern	CD		54591-3	LA10929-0	1.3.6.1.4.1.12009.10.1.55
	A1800	7	Hospice		Typical pattern	CD		54591-3	LA6216-1	1.3.6.1.4.1.12009.10.1.55
	A1800	99	Other		Typical pattern	CD		54591-3	LA46-8	1.3.6.1.4.1.12009.10.1.55
	A2000		Discharge date	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100		Discharge status	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	1	Community (private home/apt., board/ care, assisted living, group home)	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	2	Another nursing home or swing bed	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	3	Acute hospital	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	4	Psychiatric hospital	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	5	Inpatient rehabilitation facility	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	6	MR/DD facility	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	7	Hospice	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	8	Deceased	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2100	99	Other	See CDA X-Path Mapping Table 6 Implementation Guide for CDA R2 - CDA Framework/MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)
	A2200		Previous asmt reference date for signif correction		Other response data type pattern	TS		54592-1
	A2300		Assessment reference date		Other response data type pattern	TS		54593-9
	A2400A		Has resident had Medicare-covered stay		Typical pattern	CD		54594-7		1.3.6.1.4.1.12009.10.1.62
	A2400A	0	No		Typical pattern	CD		54594-7	LA32-8	1.3.6.1.4.1.12009.10.1.62
	A2400A	1	Yes		Typical pattern	CD		54594-7	LA33-6	1.3.6.1.4.1.12009.10.1.62
	A2400B		Start date of most recent Medicare stay		Other response data type pattern	TS		54595-4
	A2400C		End date of most recent Medicare stay		Other response data type pattern	TS		54596-2

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
B			Hearing, Speech, and Vision
	B0100		Comatose		Typical pattern	CD		54597-0		1.3.6.1.4.1.12009.10.1.62
	B0100	0	No		Typical pattern	CD		54597-0	LA32-8	1.3.6.1.4.1.12009.10.1.62
	B0100	1	Yes		Typical pattern	CD		54597-0	LA33-6	1.3.6.1.4.1.12009.10.1.62
	B0200		Hearing		Typical pattern	CD		54598-8		1.3.6.1.4.1.12009.10.1.53
	B0200	0	Adequate - no difficulty in normal conversation, social interaction, listening to TV		Typical pattern	CD		54598-8	LA10941-5	1.3.6.1.4.1.12009.10.1.53
	B0200	1	Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)		Typical pattern	CD		54598-8	LA10942-3	1.3.6.1.4.1.12009.10.1.53
	B0200	2	Moderate difficulty - speaker has to increase volume and speak distinctly		Typical pattern	CD		54598-8	LA10943-1	1.3.6.1.4.1.12009.10.1.53
	B0200	3	Highly impaired - absence of useful hearing		Typical pattern	CD		54598-8	LA10944-9	1.3.6.1.4.1.12009.10.1.53
	B0300		Hearing aid		Typical pattern	CD		54599-6		1.3.6.1.4.1.12009.10.1.62
	B0300	0	No		Typical pattern	CD		54599-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	B0300	1	Yes		Typical pattern	CD		54599-6	LA33-6	1.3.6.1.4.1.12009.10.1.62
	B0600		Speech clarity		Typical pattern	CD		54600-2		1.3.6.1.4.1.12009.10.1.52
	B0600	0	Clear speech - distinct intelligible words		Typical pattern	CD		54600-2	LA10945-6	1.3.6.1.4.1.12009.10.1.52
	B0600	1	Unclear speech - slurred or mumbled words		Typical pattern	CD		54600-2	LA10946-4	1.3.6.1.4.1.12009.10.1.52
	B0600	2	No speech - absence of spoken words		Typical pattern	CD		54600-2	LA10947-2	1.3.6.1.4.1.12009.10.1.52
	B0700		Makes self understood		Typical pattern	CD		54601-0		1.3.6.1.4.1.12009.10.1.51
	B0700	0	Understood		Typical pattern	CD		54601-0	LA71-6	1.3.6.1.4.1.12009.10.1.51
	B0700	1	Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time		Typical pattern	CD		54601-0	LA10949-8	1.3.6.1.4.1.12009.10.1.51
	B0700	2	Sometimes understood - ability is limited to making concrete requests		Typical pattern	CD		54601-0	LA10950-6	1.3.6.1.4.1.12009.10.1.51
	B0700	3	Rarely/never understood		Typical pattern	CD		54601-0	LA74-0	1.3.6.1.4.1.12009.10.1.51
	B0800		Ability to understand others		Typical pattern	CD		54602-8		1.3.6.1.4.1.12009.10.1.50
	B0800	0	Understands - clear comprehension		Typical pattern	CD		54602-8	LA10952-2	1.3.6.1.4.1.12009.10.1.50
	B0800	1	Usually understands - misses some part/intent of message but comprehends most conversation		Typical pattern	CD		54602-8	LA10953-0	1.3.6.1.4.1.12009.10.1.50
	B0800	2	Sometimes understands - responds adequately to simple, direct communication only		Typical pattern	CD		54602-8	LA10954-8	1.3.6.1.4.1.12009.10.1.50
	B0800	3	Rarely/never understands		Typical pattern	CD		54602-8	LA81-5	1.3.6.1.4.1.12009.10.1.50
	B1000		Vision		Typical pattern	CD		54603-6		1.3.6.1.4.1.12009.10.1.49
	B1000	0	Adequate - sees fine detail, including regular print in newspapers/books		Typical pattern	CD		54603-6	LA10956-3	1.3.6.1.4.1.12009.10.1.49
	B1000	1	Impaired - sees large print, but not regular print in newspapers/books		Typical pattern	CD		54603-6	LA10957-1	1.3.6.1.4.1.12009.10.1.49
	B1000	2	Moderately Impaired - limited vision; not able to see newspaper headlines but can identify objects		Typical pattern	CD		54603-6	LA10958-9	1.3.6.1.4.1.12009.10.1.49
	B1000	3	Highly impaired - object identification in question, but eyes appear to follow objects		Typical pattern	CD		54603-6	LA10959-7	1.3.6.1.4.1.12009.10.1.49
	B1000	4	Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects		Typical pattern	CD		54603-6	LA10960-5	1.3.6.1.4.1.12009.10.1.49
	B1200		Corrective lenses		Typical pattern	CD		54604-4		1.3.6.1.4.1.12009.10.1.62
	B1200	0	No		Typical pattern	CD		54604-4	LA32-8	1.3.6.1.4.1.12009.10.1.62
	B1200	1	Yes		Typical pattern	CD		54604-4	LA33-6	1.3.6.1.4.1.12009.10.1.62

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
C			Cognitive Patterns
	C0100		BIMS: should resident interview be conducted		Typical pattern	CD		54605-1		1.3.6.1.4.1.12009.10.1.2
	C0100	0	No (resident is rarely/never understood)		Typical pattern	CD		54605-1	LA11150-2	1.3.6.1.4.1.12009.10.1.2
	C0100	1	Yes		Typical pattern	CD		54605-1	LA33-6	1.3.6.1.4.1.12009.10.1.2
	C0200		BIMS res interview: repetition of three words		Typical pattern	CD		52731-7		1.3.6.1.4.1.12009.10.1.6
	C0200	0	None		Typical pattern	CD		52731-7	LA137-2	1.3.6.1.4.1.12009.10.1.6
	C0200	1	One		Typical pattern	CD		52731-7	LA6306-0	1.3.6.1.4.1.12009.10.1.6
	C0200	2	Two		Typical pattern	CD		52731-7	LA6404-3	1.3.6.1.4.1.12009.10.1.6
	C0200	3	Three		Typical pattern	CD		52731-7	LA6395-3	1.3.6.1.4.1.12009.10.1.6
	C0300A		BIMS res interview: able to report correct year		Typical pattern	CD		52732-5		1.3.6.1.4.1.12009.10.1.48
	C0300A	0	Missed by > 5 years or no answer		Typical pattern	CD		52732-5	LA10965-4	1.3.6.1.4.1.12009.10.1.48
	C0300A	1	Missed by 2-5 years		Typical pattern	CD		52732-5	LA10966-2	1.3.6.1.4.1.12009.10.1.48
	C0300A	2	Missed by 1 year		Typical pattern	CD		52732-5	LA10008-3	1.3.6.1.4.1.12009.10.1.48
	C0300A	3	Correct		Typical pattern	CD		52732-5	LA9960-1	1.3.6.1.4.1.12009.10.1.48
	C0300B		BIMS res interview: able to report correct month		Typical pattern	CD		52733-3		1.3.6.1.4.1.12009.10.1.47
	C0300B	0	Missed by > 1 month or no answer		Typical pattern	CD		52733-3	LA10969-6	1.3.6.1.4.1.12009.10.1.47
	C0300B	1	Missed by 6 days to 1 month		Typical pattern	CD		52733-3	LA10010-9	1.3.6.1.4.1.12009.10.1.47
	C0300B	2	Accurate within 5 days		Typical pattern	CD		52733-3	LA9927-0	1.3.6.1.4.1.12009.10.1.47
	C0300C		BIMS res interview: can report correct day of week		Typical pattern	CD		54609-3		1.3.6.1.4.1.12009.10.1.46
	C0300C	0	Incorrect or no answer		Typical pattern	CD		54609-3	LA9981-7	1.3.6.1.4.1.12009.10.1.46
	C0300C	1	Correct		Typical pattern	CD		54609-3	LA9960-1	1.3.6.1.4.1.12009.10.1.46
	C0400A		BIMS res interview: able to recall “sock”		Typical pattern	CD		52735-8		1.3.6.1.4.1.12009.10.1.45
	C0400A	0	No - could not recall		Typical pattern	CD		52735-8	LA10974-6	1.3.6.1.4.1.12009.10.1.45
	C0400A	1	Yes, after cueing (“something to wear”)		Typical pattern	CD		52735-8	LA10126-3	1.3.6.1.4.1.12009.10.1.45
	C0400A	2	Yes, no cue required		Typical pattern	CD		52735-8	LA10134-7	1.3.6.1.4.1.12009.10.1.45
	C0400B		BIMS res interview: able to recall “blue”		Typical pattern	CD		52736-6		1.3.6.1.4.1.12009.10.1.44
	C0400B	0	No - could not recall		Typical pattern	CD		52736-6	LA10974-6	1.3.6.1.4.1.12009.10.1.44
	C0400B	1	Yes, after cueing (“a color”)		Typical pattern	CD		52736-6	LA10978-7	1.3.6.1.4.1.12009.10.1.44
	C0400B	2	Yes, no cue required		Typical pattern	CD		52736-6	LA10134-7	1.3.6.1.4.1.12009.10.1.44
	C0400C		BIMS res interview: able to recall “bed”		Typical pattern	CD		52737-4		1.3.6.1.4.1.12009.10.1.43
	C0400C	0	No - could not recall		Typical pattern	CD		52737-4	LA10974-6	1.3.6.1.4.1.12009.10.1.43
	C0400C	1	Yes, after cueing (“a piece of furniture”)		Typical pattern	CD		52737-4	LA10125-5	1.3.6.1.4.1.12009.10.1.43
	C0400C	2	Yes, no cue required		Typical pattern	CD		52737-4	LA10134-7	1.3.6.1.4.1.12009.10.1.43
	C0500		BIMS res interview: summary score		Other response data type pattern	INT		54614-3
	C0600		Staff asmt mental status: conduct asmt		Typical pattern	CD		54615-0		1.3.6.1.4.1.12009.10.1.5
	C0600	0	No (resident was able to complete interview)		Typical pattern	CD		54615-0	LA11145-2	1.3.6.1.4.1.12009.10.1.5
	C0600	1	Yes (resident was unable to complete interview)		Typical pattern	CD		54615-0	LA11146-0	1.3.6.1.4.1.12009.10.1.5
	C0700		Staff asmt mental status: short-term memory OK		Typical pattern	CD		54616-8		1.3.6.1.4.1.12009.10.1.42
	C0700	0	Memory OK		Typical pattern	CD		54616-8	LA55-9	1.3.6.1.4.1.12009.10.1.42
	C0700	1	Memory problem		Typical pattern	CD		54616-8	LA56-7	1.3.6.1.4.1.12009.10.1.42
	C0800		Staff asmt mental status: long-term memory OK		Typical pattern	CD		54617-6		1.3.6.1.4.1.12009.10.1.42
	C0800	0	Memory OK		Typical pattern	CD		54617-6	LA55-9	1.3.6.1.4.1.12009.10.1.42
	C0800	1	Memory problem		Typical pattern	CD		54617-6	LA56-7	1.3.6.1.4.1.12009.10.1.42
	C0900A		Staff asmt mental status: recall current season		Multiple response pattern	BL		54619-2
	C0900B		Staff asmt mental status: recall location of room		Multiple response pattern	BL		54620-0
	C0900C		Staff asmt mental status: recall staff names/faces		Multiple response pattern	BL		54621-8
	C0900D		Staff asmt mental status: recall in nursing home		Multiple response pattern	BL		54622-6
	C0900Z		Staff asmt mental status: none of above recalled		Multiple response pattern	BL		54623-4
	C1000		Cognitive skills for daily decision making		Typical pattern	CD		54624-2		1.3.6.1.4.1.12009.10.1.41
	C1000	0	Independent - decisions consistent/reasonable		Typical pattern	CD		54624-2	LA10985-2	1.3.6.1.4.1.12009.10.1.41
	C1000	1	Modified independence - some difficulty in new situations only		Typical pattern	CD		54624-2	LA10986-0	1.3.6.1.4.1.12009.10.1.41
	C1000	2	Moderately impaired - decisions poor; cues/supervision required		Typical pattern	CD		54624-2	LA10987-8	1.3.6.1.4.1.12009.10.1.41
	C1000	3	Severely impaired - never/rarely made decisions		Typical pattern	CD		54624-2	LA10988-6	1.3.6.1.4.1.12009.10.1.41
	C1300A		Signs of delirium: inattention		Typical pattern	CD		54628-3		1.3.6.1.4.1.12009.10.1.39
	C1300A	0	Behavior not present		Typical pattern	CD		54628-3	LA61-7	1.3.6.1.4.1.12009.10.1.39
	C1300A	1	Behavior continuously present, does not fluctuate		Typical pattern	CD		54628-3	LA11143-7	1.3.6.1.4.1.12009.10.1.39
	C1300A	2	Behavior present, fluctuates (comes and goes, changes in severity)		Typical pattern	CD		54628-3	LA10993-6	1.3.6.1.4.1.12009.10.1.39
	C1300B		Signs of delirium: disorganized thinking		Typical pattern	CD		54629-1		1.3.6.1.4.1.12009.10.1.39
	C1300B	0	Behavior not present		Typical pattern	CD		54629-1	LA61-7	1.3.6.1.4.1.12009.10.1.39
	C1300B	1	Behavior continuously present, does not fluctuate		Typical pattern	CD		54629-1	LA11143-7	1.3.6.1.4.1.12009.10.1.39
	C1300B	2	Behavior present, fluctuates (comes and goes, changes in severity)		Typical pattern	CD		54629-1	LA10993-6	1.3.6.1.4.1.12009.10.1.39
	C1300C		Signs of delirium: altered level of consciousness		Typical pattern	CD		54630-9		1.3.6.1.4.1.12009.10.1.39
	C1300C	0	Behavior not present		Typical pattern	CD		54630-9	LA61-7	1.3.6.1.4.1.12009.10.1.39
	C1300C	1	Behavior continuously present, does not fluctuate		Typical pattern	CD		54630-9	LA11143-7	1.3.6.1.4.1.12009.10.1.39
	C1300C	2	Behavior present, fluctuates (comes and goes, changes in severity)		Typical pattern	CD		54630-9	LA10993-6	1.3.6.1.4.1.12009.10.1.39
	C1300D		Signs of delirium: psychomotor retardation		Typical pattern	CD		54631-7		1.3.6.1.4.1.12009.10.1.39
	C1300D	0	Behavior not present		Typical pattern	CD		54631-7	LA61-7	1.3.6.1.4.1.12009.10.1.39
	C1300D	1	Behavior continuously present, does not fluctuate		Typical pattern	CD		54631-7	LA11143-7	1.3.6.1.4.1.12009.10.1.39
	C1300D	2	Behavior present, fluctuates (comes and goes, changes in severity)		Typical pattern	CD		54631-7	LA10993-6	1.3.6.1.4.1.12009.10.1.39
	C1600		Acute onset mental status change		Typical pattern	CD		54632-5		1.3.6.1.4.1.12009.10.1.62
	C1600	0	No		Typical pattern	CD		54632-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	C1600	1	Yes		Typical pattern	CD		54632-5	LA33-6	1.3.6.1.4.1.12009.10.1.62

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
D			Mood
	D0100		PHQ: should resident mood interview be conducted		Typical pattern	CD		54634-1		1.3.6.1.4.1.12009.10.1.2
	D0100	0	No (resident is rarely/never understood)		Typical pattern	CD		54634-1	LA11150-2	1.3.6.1.4.1.12009.10.1.2
	D0100	1	Yes		Typical pattern	CD		54634-1	LA33-6	1.3.6.1.4.1.12009.10.1.2
	D0200A1		PHQ res: little interest or pleasure - presence		Typical pattern	CD		54636-6		1.3.6.1.4.1.12009.10.1.38
	D0200A1	0	No (enter 0 in column 2)		Typical pattern	CD		54636-6	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200A1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54636-6	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200A1	9	No response (leave column 2 blank)		Typical pattern	CD		54636-6	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200A2		PHQ res: little interest or pleasure - frequency		Typical pattern	CD		54637-4		1.3.6.1.4.1.12009.10.1.37
	D0200A2	0	Never or 1 day		Typical pattern	CD		54637-4	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200A2	1	2-6 Days (Several days)		Typical pattern	CD		54637-4	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200A2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54637-4	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200A2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54637-4	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200B1		PHQ res: feeling down, depressed - presence		Typical pattern	CD		54638-2		1.3.6.1.4.1.12009.10.1.38
	D0200B1	0	No (enter 0 in column 2)		Typical pattern	CD		54638-2	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200B1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54638-2	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200B1	9	No response (leave column 2 blank)		Typical pattern	CD		54638-2	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200B2		PHQ res: feeling down, depressed - frequency		Typical pattern	CD		54639-0		1.3.6.1.4.1.12009.10.1.37
	D0200B2	0	Never or 1 day		Typical pattern	CD		54639-0	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200B2	1	2-6 Days (Several days)		Typical pattern	CD		54639-0	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200B2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54639-0	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200B2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54639-0	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200C1		PHQ res: trouble with sleep - presence		Typical pattern	CD		54640-8		1.3.6.1.4.1.12009.10.1.38
	D0200C1	0	No (enter 0 in column 2)		Typical pattern	CD		54640-8	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200C1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54640-8	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200C1	9	No response (leave column 2 blank)		Typical pattern	CD		54640-8	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200C2		PHQ res: trouble with sleep - frequency		Typical pattern	CD		54641-6		1.3.6.1.4.1.12009.10.1.37
	D0200C2	0	Never or 1 day		Typical pattern	CD		54641-6	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200C2	1	2-6 Days (Several days)		Typical pattern	CD		54641-6	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200C2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54641-6	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200C2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54641-6	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200D1		PHQ res: feeling tired/little energy - presence		Typical pattern	CD		54642-4		1.3.6.1.4.1.12009.10.1.38
	D0200D1	0	No (enter 0 in column 2)		Typical pattern	CD		54642-4	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200D1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54642-4	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200D1	9	No response (leave column 2 blank)		Typical pattern	CD		54642-4	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200D2		PHQ res: feeling tired/little energy - frequency		Typical pattern	CD		54643-2		1.3.6.1.4.1.12009.10.1.37
	D0200D2	0	Never or 1 day		Typical pattern	CD		54643-2	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200D2	1	2-6 Days (Several days)		Typical pattern	CD		54643-2	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200D2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54643-2	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200D2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54643-2	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200E1		PHQ res: poor appetite or overeating - presence		Typical pattern	CD		54644-0		1.3.6.1.4.1.12009.10.1.38
	D0200E1	0	No (enter 0 in column 2)		Typical pattern	CD		54644-0	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200E1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54644-0	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200E1	9	No response (leave column 2 blank)		Typical pattern	CD		54644-0	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200E2		PHQ res: poor appetite or overeating - frequency		Typical pattern	CD		54645-7		1.3.6.1.4.1.12009.10.1.37
	D0200E2	0	Never or 1 day		Typical pattern	CD		54645-7	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200E2	1	2-6 Days (Several days)		Typical pattern	CD		54645-7	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200E2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54645-7	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200E2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54645-7	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200F1		PHQ res: feeling bad about self - presence		Typical pattern	CD		54646-5		1.3.6.1.4.1.12009.10.1.38
	D0200F1	0	No (enter 0 in column 2)		Typical pattern	CD		54646-5	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200F1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54646-5	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200F1	9	No response (leave column 2 blank)		Typical pattern	CD		54646-5	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200F2		PHQ res: feeling bad about self - frequency		Typical pattern	CD		54647-3		1.3.6.1.4.1.12009.10.1.37
	D0200F2	0	Never or 1 day		Typical pattern	CD		54647-3	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200F2	1	2-6 Days (Several days)		Typical pattern	CD		54647-3	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200F2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54647-3	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200F2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54647-3	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200G1		PHQ res: trouble concentrating - presence		Typical pattern	CD		54648-1		1.3.6.1.4.1.12009.10.1.38
	D0200G1	0	No (enter 0 in column 2)		Typical pattern	CD		54648-1	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200G1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54648-1	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200G1	9	No response (leave column 2 blank)		Typical pattern	CD		54648-1	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200G2		PHQ res: trouble concentrating - frequency		Typical pattern	CD		54649-9		1.3.6.1.4.1.12009.10.1.37
	D0200G2	0	Never or 1 day		Typical pattern	CD		54649-9	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200G2	1	2-6 Days (Several days)		Typical pattern	CD		54649-9	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200G2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54649-9	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200G2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54649-9	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200H1		PHQ res: slow, fidgety, restless - presence		Typical pattern	CD		54650-7		1.3.6.1.4.1.12009.10.1.38
	D0200H1	0	No (enter 0 in column 2)		Typical pattern	CD		54650-7	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200H1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54650-7	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200H1	9	No response (leave column 2 blank)		Typical pattern	CD		54650-7	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200H2		PHQ res: slow, fidgety, restless - frequency		Typical pattern	CD		54651-5		1.3.6.1.4.1.12009.10.1.37
	D0200H2	0	Never or 1 day		Typical pattern	CD		54651-5	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200H2	1	2-6 Days (Several days)		Typical pattern	CD		54651-5	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200H2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54651-5	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200H2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54651-5	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0200I1		PHQ res: thoughts better off dead - presence		Typical pattern	CD		54652-3		1.3.6.1.4.1.12009.10.1.38
	D0200I1	0	No (enter 0 in column 2)		Typical pattern	CD		54652-3	LA32-8	1.3.6.1.4.1.12009.10.1.38
	D0200I1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54652-3	LA33-6	1.3.6.1.4.1.12009.10.1.38
	D0200I1	9	No response (leave column 2 blank)		Typical pattern	CD		54652-3	LA10996-9	1.3.6.1.4.1.12009.10.1.38
	D0200I2		PHQ res: thoughts better off dead - frequency		Typical pattern	CD		54653-1		1.3.6.1.4.1.12009.10.1.37
	D0200I2	0	Never or 1 day		Typical pattern	CD		54653-1	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0200I2	1	2-6 Days (Several days)		Typical pattern	CD		54653-1	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0200I2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54653-1	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0200I2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54653-1	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0300		PHQ res: total mood severity score		Other response data type pattern	INT		54654-9
	D0350		PHQ res: safety notification		Typical pattern	CD		54655-6		1.3.6.1.4.1.12009.10.1.62
	D0350	0	No		Typical pattern	CD		54655-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0350	1	Yes		Typical pattern	CD		54655-6	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500A1		PHQ staff: little interest or pleasure - presence		Typical pattern	CD		54658-0		1.3.6.1.4.1.12009.10.1.62
	D0500A1	0	No (enter 0 in column 2)		Typical pattern	CD		54658-0	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500A1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54658-0	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500A2		PHQ staff: little interest or pleasure - frequency		Typical pattern	CD		54659-8		1.3.6.1.4.1.12009.10.1.37
	D0500A2	0	Never or 1 day		Typical pattern	CD		54659-8	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500A2	1	2-6 Days (Several days)		Typical pattern	CD		54659-8	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500A2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54659-8	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500A2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54659-8	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500B1		PHQ staff: feeling down, depressed - presence		Typical pattern	CD		54660-6		1.3.6.1.4.1.12009.10.1.62
	D0500B1	0	No (enter 0 in column 2)		Typical pattern	CD		54660-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500B1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54660-6	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500B2		PHQ staff: feeling down, depressed - frequency		Typical pattern	CD		54661-4		1.3.6.1.4.1.12009.10.1.37
	D0500B2	0	Never or 1 day		Typical pattern	CD		54661-4	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500B2	1	2-6 Days (Several days)		Typical pattern	CD		54661-4	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500B2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54661-4	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500B2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54661-4	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500C1		PHQ staff: trouble with sleep - presence		Typical pattern	CD		54662-2		1.3.6.1.4.1.12009.10.1.62
	D0500C1	0	No (enter 0 in column 2)		Typical pattern	CD		54662-2	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500C1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54662-2	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500C2		PHQ staff: trouble with sleep - frequency		Typical pattern	CD		54663-0		1.3.6.1.4.1.12009.10.1.37
	D0500C2	0	Never or 1 day		Typical pattern	CD		54663-0	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500C2	1	2-6 Days (Several days)		Typical pattern	CD		54663-0	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500C2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54663-0	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500C2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54663-0	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500D1		PHQ staff: feeling tired/little energy - presence		Typical pattern	CD		54664-8		1.3.6.1.4.1.12009.10.1.62
	D0500D1	0	No (enter 0 in column 2)		Typical pattern	CD		54664-8	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500D1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54664-8	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500D2		PHQ staff: feeling tired/little energy - frequency		Typical pattern	CD		54665-5		1.3.6.1.4.1.12009.10.1.37
	D0500D2	0	Never or 1 day		Typical pattern	CD		54665-5	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500D2	1	2-6 Days (Several days)		Typical pattern	CD		54665-5	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500D2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54665-5	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500D2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54665-5	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500E1		PHQ staff: poor appetite or overeating - presence		Typical pattern	CD		54666-3		1.3.6.1.4.1.12009.10.1.62
	D0500E1	0	No (enter 0 in column 2)		Typical pattern	CD		54666-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500E1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54666-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500E2		PHQ staff: poor appetite or overeating - frequency		Typical pattern	CD		54667-1		1.3.6.1.4.1.12009.10.1.37
	D0500E2	0	Never or 1 day		Typical pattern	CD		54667-1	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500E2	1	2-6 Days (Several days)		Typical pattern	CD		54667-1	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500E2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54667-1	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500E2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54667-1	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500F1		PHQ staff: feeling bad about self - presence		Typical pattern	CD		54668-9		1.3.6.1.4.1.12009.10.1.62
	D0500F1	0	No (enter 0 in column 2)		Typical pattern	CD		54668-9	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500F1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54668-9	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500F2		PHQ staff: feeling bad about self - frequency		Typical pattern	CD		54669-7		1.3.6.1.4.1.12009.10.1.37
	D0500F2	0	Never or 1 day		Typical pattern	CD		54669-7	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500F2	1	2-6 Days (Several days)		Typical pattern	CD		54669-7	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500F2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54669-7	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500F2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54669-7	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500G1		PHQ staff: trouble concentrating - presence		Typical pattern	CD		54670-5		1.3.6.1.4.1.12009.10.1.62
	D0500G1	0	No (enter 0 in column 2)		Typical pattern	CD		54670-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500G1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54670-5	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500G2		PHQ staff: trouble concentrating - frequency		Typical pattern	CD		54671-3		1.3.6.1.4.1.12009.10.1.37
	D0500G2	0	Never or 1 day		Typical pattern	CD		54671-3	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500G2	1	2-6 Days (Several days)		Typical pattern	CD		54671-3	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500G2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54671-3	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500G2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54671-3	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500H1		PHQ staff: slow, fidgety, restless - presence		Typical pattern	CD		54672-1		1.3.6.1.4.1.12009.10.1.62
	D0500H1	0	No (enter 0 in column 2)		Typical pattern	CD		54672-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500H1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54672-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500H2		PHQ staff: slow, fidgety, restless - frequency		Typical pattern	CD		54904-8		1.3.6.1.4.1.12009.10.1.37
	D0500H2	0	Never or 1 day		Typical pattern	CD		54904-8	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500H2	1	2-6 Days (Several days)		Typical pattern	CD		54904-8	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500H2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54904-8	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500H2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54904-8	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500I1		PHQ staff: thoughts better off dead - presence		Typical pattern	CD		54673-9		1.3.6.1.4.1.12009.10.1.62
	D0500I1	0	No (enter 0 in column 2)		Typical pattern	CD		54673-9	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500I1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54673-9	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500I2		PHQ staff: thoughts better off dead - frequency		Typical pattern	CD		54674-7		1.3.6.1.4.1.12009.10.1.37
	D0500I2	0	Never or 1 day		Typical pattern	CD		54674-7	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500I2	1	2-6 Days (Several days)		Typical pattern	CD		54674-7	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500I2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54674-7	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500I2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54674-7	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0500J1		PHQ staff: short-tempered - presence		Typical pattern	CD		54675-4		1.3.6.1.4.1.12009.10.1.62
	D0500J1	0	No (enter 0 in column 2)		Typical pattern	CD		54675-4	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0500J1	1	Yes (enter 0-3 in column 2)		Typical pattern	CD		54675-4	LA33-6	1.3.6.1.4.1.12009.10.1.62
	D0500J2		PHQ staff: short-tempered - frequency		Typical pattern	CD		54676-2		1.3.6.1.4.1.12009.10.1.37
	D0500J2	0	Never or 1 day		Typical pattern	CD		54676-2	LA10997-7	1.3.6.1.4.1.12009.10.1.37
	D0500J2	1	2-6 Days (Several days)		Typical pattern	CD		54676-2	LA10998-5	1.3.6.1.4.1.12009.10.1.37
	D0500J2	2	7-11 Days (Half or more of the days)		Typical pattern	CD		54676-2	LA10999-3	1.3.6.1.4.1.12009.10.1.37
	D0500J2	3	12-14 Days (Nearly every day)		Typical pattern	CD		54676-2	LA11000-9	1.3.6.1.4.1.12009.10.1.37
	D0600		PHQ staff: total mood score		Other response data type pattern	INT		54677-0
	D0650		PHQ staff: safety notification		Typical pattern	CD		54655-6		1.3.6.1.4.1.12009.10.1.62
	D0650	0	No		Typical pattern	CD		54655-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	D0650	1	Yes		Typical pattern	CD		54655-6	LA33-6	1.3.6.1.4.1.12009.10.1.62

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
E			Behavior
	E0100A		Psychosis: hallucinations		Multiple response pattern	BL		54678-8
	E0100B		Psychosis: delusions		Multiple response pattern	BL		54680-4
	E0100Z		Psychosis: none of the above		Multiple response pattern	BL		54681-2
	E0200A		Physical behav symptoms directed toward others		Typical pattern	CD		54682-0		1.3.6.1.4.1.12009.10.1.35
	E0200A	0	Behavior not exhibited		Typical pattern	CD		54682-0	LA11005-8	1.3.6.1.4.1.12009.10.1.35
	E0200A	1	Behavior of this type occurred 1 to 3 days		Typical pattern	CD		54682-0	LA11006-6	1.3.6.1.4.1.12009.10.1.35
	E0200A	2	Behavior of this type occurred 4 to 6 days, but less than daily		Typical pattern	CD		54682-0	LA94-8	1.3.6.1.4.1.12009.10.1.35
	E0200A	3	Behavior of this type occurred daily		Typical pattern	CD		54682-0	LA95-5	1.3.6.1.4.1.12009.10.1.35
	E0200B		Verbal behav symptoms directed toward others		Typical pattern	CD		54683-8		1.3.6.1.4.1.12009.10.1.35
	E0200B	0	Behavior not exhibited		Typical pattern	CD		54683-8	LA11005-8	1.3.6.1.4.1.12009.10.1.35
	E0200B	1	Behavior of this type occurred 1 to 3 days		Typical pattern	CD		54683-8	LA11006-6	1.3.6.1.4.1.12009.10.1.35
	E0200B	2	Behavior of this type occurred 4 to 6 days, but less than daily		Typical pattern	CD		54683-8	LA94-8	1.3.6.1.4.1.12009.10.1.35
	E0200B	3	Behavior of this type occurred daily		Typical pattern	CD		54683-8	LA95-5	1.3.6.1.4.1.12009.10.1.35
	E0200C		Other behav symptoms not directed toward others		Typical pattern	CD		54684-6		1.3.6.1.4.1.12009.10.1.35
	E0200C	0	Behavior not exhibited		Typical pattern	CD		54684-6	LA11005-8	1.3.6.1.4.1.12009.10.1.35
	E0200C	1	Behavior of this type occurred 1 to 3 days		Typical pattern	CD		54684-6	LA11006-6	1.3.6.1.4.1.12009.10.1.35
	E0200C	2	Behavior of this type occurred 4 to 6 days, but less than daily		Typical pattern	CD		54684-6	LA94-8	1.3.6.1.4.1.12009.10.1.35
	E0200C	3	Behavior of this type occurred daily		Typical pattern	CD		54684-6	LA95-5	1.3.6.1.4.1.12009.10.1.35
	E0300		Overall presence of behavioral symptoms		Typical pattern	CD		54685-3		1.3.6.1.4.1.12009.10.1.62
	E0300	0	No		Typical pattern	CD		54685-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0300	1	Yes		Typical pattern	CD		54685-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0500A		Behav symptoms put res at risk for illness/injury		Typical pattern	CD		54686-1		1.3.6.1.4.1.12009.10.1.62
	E0500A	0	No		Typical pattern	CD		54686-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0500A	1	Yes		Typical pattern	CD		54686-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0500B		Behav symptoms interfere with resident care		Typical pattern	CD		54687-9		1.3.6.1.4.1.12009.10.1.62
	E0500B	0	No		Typical pattern	CD		54687-9	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0500B	1	Yes		Typical pattern	CD		54687-9	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0500C		Behav symptoms interfere with social activities		Typical pattern	CD		54688-7		1.3.6.1.4.1.12009.10.1.62
	E0500C	0	No		Typical pattern	CD		54688-7	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0500C	1	Yes		Typical pattern	CD		54688-7	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0600A		Behav symptoms put others at risk for injury		Typical pattern	CD		54689-5		1.3.6.1.4.1.12009.10.1.62
	E0600A	0	No		Typical pattern	CD		54689-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0600A	1	Yes		Typical pattern	CD		54689-5	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0600B		Behav symptoms intrude on privacy of others		Typical pattern	CD		54690-3		1.3.6.1.4.1.12009.10.1.62
	E0600B	0	No		Typical pattern	CD		54690-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0600B	1	Yes		Typical pattern	CD		54690-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0600C		Behav symptoms disrupt care or living environment		Typical pattern	CD		54691-1		1.3.6.1.4.1.12009.10.1.62
	E0600C	0	No		Typical pattern	CD		54691-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E0600C	1	Yes		Typical pattern	CD		54691-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E0800		Rejection of care: presence and frequency		Typical pattern	CD		54692-9		1.3.6.1.4.1.12009.10.1.35
	E0800	0	Behavior not exhibited		Typical pattern	CD		54692-9	LA11005-8	1.3.6.1.4.1.12009.10.1.35
	E0800	1	Behavior of this type occurred 1 to 3 days		Typical pattern	CD		54692-9	LA11006-6	1.3.6.1.4.1.12009.10.1.35
	E0800	2	Behavior of this type occurred 4 to 6 days, but less than daily		Typical pattern	CD		54692-9	LA94-8	1.3.6.1.4.1.12009.10.1.35
	E0800	3	Behavior of this type occurred daily		Typical pattern	CD		54692-9	LA95-5	1.3.6.1.4.1.12009.10.1.35
	E0900		Wandering: presence and frequency		Typical pattern	CD		54693-7		1.3.6.1.4.1.12009.10.1.35
	E0900	0	Behavior not exhibited		Typical pattern	CD		54693-7	LA11005-8	1.3.6.1.4.1.12009.10.1.35
	E0900	1	Behavior of this type occurred 1 to 3 days		Typical pattern	CD		54693-7	LA11006-6	1.3.6.1.4.1.12009.10.1.35
	E0900	2	Behavior of this type occurred 4 to 6 days, but less than daily		Typical pattern	CD		54693-7	LA94-8	1.3.6.1.4.1.12009.10.1.35
	E0900	3	Behavior of this type occurred daily		Typical pattern	CD		54693-7	LA95-5	1.3.6.1.4.1.12009.10.1.35
	E1000A		Wandering: risk of getting to dangerous place		Typical pattern	CD		54694-5		1.3.6.1.4.1.12009.10.1.62
	E1000A	0	No		Typical pattern	CD		54694-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E1000A	1	Yes		Typical pattern	CD		54694-5	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E1000B		Wandering: intrude on privacy of others		Typical pattern	CD		54695-2		1.3.6.1.4.1.12009.10.1.62
	E1000B	0	No		Typical pattern	CD		54695-2	LA32-8	1.3.6.1.4.1.12009.10.1.62
	E1000B	1	Yes		Typical pattern	CD		54695-2	LA33-6	1.3.6.1.4.1.12009.10.1.62
	E1100		Change in behavioral or other symptoms		Typical pattern	CD		54696-0		1.3.6.1.4.1.12009.10.1.34
	E1100	0	Same		Typical pattern	CD		54696-0	LA11009-0	1.3.6.1.4.1.12009.10.1.34
	E1100	1	Improved		Typical pattern	CD		54696-0	LA65-8	1.3.6.1.4.1.12009.10.1.34
	E1100	2	Worse		Typical pattern	CD		54696-0	LA11011-6	1.3.6.1.4.1.12009.10.1.34
	E1100	9	N/A because no prior MDS assessment		Typical pattern	CD		54696-0	LA11012-4	1.3.6.1.4.1.12009.10.1.34

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
F			Preferences for Customary Routine and Activities
	F0300		Conduct res interview for daily/activity prefs		Typical pattern	CD		54697-8		1.3.6.1.4.1.12009.10.1.3
	F0300	0	No (resident is rarely/never understood and family/ significant other not available)		Typical pattern	CD		54697-8	LA11149-4	1.3.6.1.4.1.12009.10.1.3
	F0300	1	Yes		Typical pattern	CD		54697-8	LA33-6	1.3.6.1.4.1.12009.10.1.3
	F0400A		Res interview: choose clothes to wear		Typical pattern	CD		54698-6		1.3.6.1.4.1.12009.10.1.33
	F0400A	1	Very important		Typical pattern	CD		54698-6	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400A	2	Somewhat important		Typical pattern	CD		54698-6	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400A	3	Not very important		Typical pattern	CD		54698-6	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400A	4	Not important at all		Typical pattern	CD		54698-6	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400A	5	Important, but can't do or no choice		Typical pattern	CD		54698-6	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400A	9	No response or non-responsive		Typical pattern	CD		54698-6	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400B		Res interview: take care of personal belongings		Typical pattern	CD		54699-4		1.3.6.1.4.1.12009.10.1.33
	F0400B	1	Very important		Typical pattern	CD		54699-4	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400B	2	Somewhat important		Typical pattern	CD		54699-4	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400B	3	Not very important		Typical pattern	CD		54699-4	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400B	4	Not important at all		Typical pattern	CD		54699-4	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400B	5	Important, but can't do or no choice		Typical pattern	CD		54699-4	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400B	9	No response or non-responsive		Typical pattern	CD		54699-4	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400C		Res interview: choose tub, bath, shower, sponge		Typical pattern	CD		54700-0		1.3.6.1.4.1.12009.10.1.33
	F0400C	1	Very important		Typical pattern	CD		54700-0	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400C	2	Somewhat important		Typical pattern	CD		54700-0	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400C	3	Not very important		Typical pattern	CD		54700-0	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400C	4	Not important at all		Typical pattern	CD		54700-0	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400C	5	Important, but can't do or no choice		Typical pattern	CD		54700-0	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400C	9	No response or non-responsive		Typical pattern	CD		54700-0	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400D		Res interview: have snacks between meals		Typical pattern	CD		54701-8		1.3.6.1.4.1.12009.10.1.33
	F0400D	1	Very important		Typical pattern	CD		54701-8	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400D	2	Somewhat important		Typical pattern	CD		54701-8	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400D	3	Not very important		Typical pattern	CD		54701-8	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400D	4	Not important at all		Typical pattern	CD		54701-8	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400D	5	Important, but can't do or no choice		Typical pattern	CD		54701-8	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400D	9	No response or non-responsive		Typical pattern	CD		54701-8	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400E		Res interview: choose own bedtime		Typical pattern	CD		54702-6		1.3.6.1.4.1.12009.10.1.33
	F0400E	1	Very important		Typical pattern	CD		54702-6	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400E	2	Somewhat important		Typical pattern	CD		54702-6	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400E	3	Not very important		Typical pattern	CD		54702-6	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400E	4	Not important at all		Typical pattern	CD		54702-6	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400E	5	Important, but can't do or no choice		Typical pattern	CD		54702-6	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400E	9	No response or non-responsive		Typical pattern	CD		54702-6	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400F		Res interview: discuss care with family/friend		Typical pattern	CD		54703-4		1.3.6.1.4.1.12009.10.1.33
	F0400F	1	Very important		Typical pattern	CD		54703-4	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400F	2	Somewhat important		Typical pattern	CD		54703-4	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400F	3	Not very important		Typical pattern	CD		54703-4	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400F	4	Not important at all		Typical pattern	CD		54703-4	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400F	5	Important, but can't do or no choice		Typical pattern	CD		54703-4	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400F	9	No response or non-responsive		Typical pattern	CD		54703-4	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400G		Res interview: use phone in private		Typical pattern	CD		54704-2		1.3.6.1.4.1.12009.10.1.33
	F0400G	1	Very important		Typical pattern	CD		54704-2	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400G	2	Somewhat important		Typical pattern	CD		54704-2	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400G	3	Not very important		Typical pattern	CD		54704-2	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400G	4	Not important at all		Typical pattern	CD		54704-2	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400G	5	Important, but can't do or no choice		Typical pattern	CD		54704-2	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400G	9	No response or non-responsive		Typical pattern	CD		54704-2	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0400H		Res interview: lock things to keep them safe		Typical pattern	CD		54705-9		1.3.6.1.4.1.12009.10.1.33
	F0400H	1	Very important		Typical pattern	CD		54705-9	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0400H	2	Somewhat important		Typical pattern	CD		54705-9	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0400H	3	Not very important		Typical pattern	CD		54705-9	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0400H	4	Not important at all		Typical pattern	CD		54705-9	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0400H	5	Important, but can't do or no choice		Typical pattern	CD		54705-9	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0400H	9	No response or non-responsive		Typical pattern	CD		54705-9	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500A		Res interview: have books, newspaper, mags to read		Typical pattern	CD		54706-7		1.3.6.1.4.1.12009.10.1.33
	F0500A	1	Very important		Typical pattern	CD		54706-7	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500A	2	Somewhat important		Typical pattern	CD		54706-7	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500A	3	Not very important		Typical pattern	CD		54706-7	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500A	4	Not important at all		Typical pattern	CD		54706-7	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500A	5	Important, but can't do or no choice		Typical pattern	CD		54706-7	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500A	9	No response or non-responsive		Typical pattern	CD		54706-7	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500B		Res interview: listen to music		Typical pattern	CD		54707-5		1.3.6.1.4.1.12009.10.1.33
	F0500B	1	Very important		Typical pattern	CD		54707-5	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500B	2	Somewhat important		Typical pattern	CD		54707-5	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500B	3	Not very important		Typical pattern	CD		54707-5	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500B	4	Not important at all		Typical pattern	CD		54707-5	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500B	5	Important, but can't do or no choice		Typical pattern	CD		54707-5	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500B	9	No response or non-responsive		Typical pattern	CD		54707-5	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500C		Res interview: be around animals/pets		Typical pattern	CD		54708-3		1.3.6.1.4.1.12009.10.1.33
	F0500C	1	Very important		Typical pattern	CD		54708-3	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500C	2	Somewhat important		Typical pattern	CD		54708-3	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500C	3	Not very important		Typical pattern	CD		54708-3	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500C	4	Not important at all		Typical pattern	CD		54708-3	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500C	5	Important, but can't do or no choice		Typical pattern	CD		54708-3	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500C	9	No response or non-responsive		Typical pattern	CD		54708-3	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500D		Res interview: keep up with news		Typical pattern	CD		54709-1		1.3.6.1.4.1.12009.10.1.33
	F0500D	1	Very important		Typical pattern	CD		54709-1	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500D	2	Somewhat important		Typical pattern	CD		54709-1	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500D	3	Not very important		Typical pattern	CD		54709-1	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500D	4	Not important at all		Typical pattern	CD		54709-1	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500D	5	Important, but can't do or no choice		Typical pattern	CD		54709-1	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500D	9	No response or non-responsive		Typical pattern	CD		54709-1	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500E		Res interview: do things with groups of people		Typical pattern	CD		54710-9		1.3.6.1.4.1.12009.10.1.33
	F0500E	1	Very important		Typical pattern	CD		54710-9	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500E	2	Somewhat important		Typical pattern	CD		54710-9	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500E	3	Not very important		Typical pattern	CD		54710-9	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500E	4	Not important at all		Typical pattern	CD		54710-9	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500E	5	Important, but can't do or no choice		Typical pattern	CD		54710-9	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500E	9	No response or non-responsive		Typical pattern	CD		54710-9	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500F		Res interview: do favorite activities		Typical pattern	CD		54711-7		1.3.6.1.4.1.12009.10.1.33
	F0500F	1	Very important		Typical pattern	CD		54711-7	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500F	2	Somewhat important		Typical pattern	CD		54711-7	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500F	3	Not very important		Typical pattern	CD		54711-7	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500F	4	Not important at all		Typical pattern	CD		54711-7	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500F	5	Important, but can't do or no choice		Typical pattern	CD		54711-7	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500F	9	No response or non-responsive		Typical pattern	CD		54711-7	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500G		Res interview: go outside when good weather		Typical pattern	CD		54712-5		1.3.6.1.4.1.12009.10.1.33
	F0500G	1	Very important		Typical pattern	CD		54712-5	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500G	2	Somewhat important		Typical pattern	CD		54712-5	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500G	3	Not very important		Typical pattern	CD		54712-5	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500G	4	Not important at all		Typical pattern	CD		54712-5	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500G	5	Important, but can't do or no choice		Typical pattern	CD		54712-5	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500G	9	No response or non-responsive		Typical pattern	CD		54712-5	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0500H		Res interview: participate in religious practices		Typical pattern	CD		54713-3		1.3.6.1.4.1.12009.10.1.33
	F0500H	1	Very important		Typical pattern	CD		54713-3	LA11013-2	1.3.6.1.4.1.12009.10.1.33
	F0500H	2	Somewhat important		Typical pattern	CD		54713-3	LA11014-0	1.3.6.1.4.1.12009.10.1.33
	F0500H	3	Not very important		Typical pattern	CD		54713-3	LA11015-7	1.3.6.1.4.1.12009.10.1.33
	F0500H	4	Not important at all		Typical pattern	CD		54713-3	LA11016-5	1.3.6.1.4.1.12009.10.1.33
	F0500H	5	Important, but can't do or no choice		Typical pattern	CD		54713-3	LA11017-3	1.3.6.1.4.1.12009.10.1.33
	F0500H	9	No response or non-responsive		Typical pattern	CD		54713-3	LA11018-1	1.3.6.1.4.1.12009.10.1.33
	F0600		Primary respondent: daily/ activities prefs		Typical pattern	CD		54714-1		1.3.6.1.4.1.12009.10.1.7
	F0600	1	Resident		Typical pattern	CD		54714-1	LA11019-9	1.3.6.1.4.1.12009.10.1.7
	F0600	2	Family or significant other (close friend or other representative)		Typical pattern	CD		54714-1	LA11020-7	1.3.6.1.4.1.12009.10.1.7
	F0600	9	Interview could not be completed by resident or family/ significant other (“No Response” to 3 or more items)		Typical pattern	CD		54714-1	LA11021-5	1.3.6.1.4.1.12009.10.1.7
	F0700		Conduct staff assessment for daily/activity prefs		Typical pattern	CD		54715-8		1.3.6.1.4.1.12009.10.1.1
	F0700	0	No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other)		Typical pattern	CD		54715-8	LA11151-0	1.3.6.1.4.1.12009.10.1.1
	F0700	1	Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other)		Typical pattern	CD		54715-8	LA11152-8	1.3.6.1.4.1.12009.10.1.1
	F0800A		Staff assessment: choosing clothes to wear		Multiple response pattern	BL		54716-6
	F0800B		Staff assessment: caring for personal belongings		Multiple response pattern	BL		54717-4
	F0800C		Staff assessment: receiving tub bath		Multiple response pattern	BL		54718-2
	F0800D		Staff assessment: receiving shower		Multiple response pattern	BL		54719-0
	F0800E		Staff assessment: receiving bed bath		Multiple response pattern	BL		54720-8
	F0800F		Staff assessment: receiving sponge bath		Multiple response pattern	BL		54721-6
	F0800G		Staff assessment: snacks between meals		Multiple response pattern	BL		54722-4
	F0800H		Staff assessment: staying up past 8PM		Multiple response pattern	BL		54723-2
	F0800I		Staff assessment: discuss care with family/other		Multiple response pattern	BL		54724-0
	F0800J		Staff assessment: use phone in private		Multiple response pattern	BL		54725-7
	F0800K		Staff assessment: place to lock personal things		Multiple response pattern	BL		54726-5
	F0800L		Staff assessment: reading books, newspapers, mags		Multiple response pattern	BL		54727-3
	F0800M		Staff assessment: listening to music		Multiple response pattern	BL		54728-1
	F0800N		Staff assessment: being around animals/pets		Multiple response pattern	BL		54729-9
	F0800O		Staff assessment: keeping up with news		Multiple response pattern	BL		54730-7
	F0800P		Staff assessment: doing things with groups		Multiple response pattern	BL		54731-5
	F0800Q		Staff assessment: participate favorite activities		Multiple response pattern	BL		54732-3
	F0800R		Staff assessment: spend time away from nursing home		Multiple response pattern	BL		54733-1
	F0800S		Staff assessment: spend time outdoors		Multiple response pattern	BL		54734-9
	F0800T		Staff assessment: participate religious activities		Multiple response pattern	BL		54735-6
	F0800Z		Staff assessment: none of above activities		Multiple response pattern	BL		54736-4

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
G			Functional Status
	G0110A1		Bed mobility: self-performance		Typical pattern	CD		45588-1		1.3.6.1.4.1.12009.10.1.70
	G0110A1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45588-1	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110A1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45588-1	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110A1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45588-1	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110A1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45588-1	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110A1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45588-1	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110A1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45588-1	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110A1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45588-1	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110A2		Bed mobility: support provided		Typical pattern	CD		45589-9		1.3.6.1.4.1.12009.10.1.160
	G0110A2	0	No setup or physical help from staff		Typical pattern	CD		45589-9	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110A2	1	Setup help only		Typical pattern	CD		45589-9	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110A2	2	One person physical assist		Typical pattern	CD		45589-9	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110A2	3	Two+ persons physical assist		Typical pattern	CD		45589-9	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110A2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45589-9	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110B1		Transfer: self-performance		Typical pattern	CD		45590-7		1.3.6.1.4.1.12009.10.1.70
	G0110B1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45590-7	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110B1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45590-7	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110B1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45590-7	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110B1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45590-7	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110B1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45590-7	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110B1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45590-7	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110B1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45590-7	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110B2		Transfer: support provided		Typical pattern	CD		45591-5		1.3.6.1.4.1.12009.10.1.160
	G0110B2	0	No setup or physical help from staff		Typical pattern	CD		45591-5	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110B2	1	Setup help only		Typical pattern	CD		45591-5	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110B2	2	One person physical assist		Typical pattern	CD		45591-5	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110B2	3	Two+ persons physical assist		Typical pattern	CD		45591-5	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110B2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45591-5	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110C1		Walk in room: self-performance		Typical pattern	CD		45592-3		1.3.6.1.4.1.12009.10.1.70
	G0110C1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45592-3	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110C1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45592-3	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110C1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45592-3	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110C1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45592-3	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110C1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45592-3	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110C1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45592-3	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110C1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45592-3	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110C2		Walk in room: support provided		Typical pattern	CD		45593-1		1.3.6.1.4.1.12009.10.1.160
	G0110C2	0	No setup or physical help from staff		Typical pattern	CD		45593-1	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110C2	1	Setup help only		Typical pattern	CD		45593-1	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110C2	2	One person physical assist		Typical pattern	CD		45593-1	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110C2	3	Two+ persons physical assist		Typical pattern	CD		45593-1	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110C2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45593-1	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110D1		Walk in corridor: self-performance		Typical pattern	CD		45594-9		1.3.6.1.4.1.12009.10.1.70
	G0110D1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45594-9	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110D1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45594-9	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110D1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45594-9	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110D1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45594-9	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110D1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45594-9	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110D1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45594-9	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110D1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45594-9	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110D2		Walk in corridor: support provided		Typical pattern	CD		45595-6		1.3.6.1.4.1.12009.10.1.160
	G0110D2	0	No setup or physical help from staff		Typical pattern	CD		45595-6	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110D2	1	Setup help only		Typical pattern	CD		45595-6	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110D2	2	One person physical assist		Typical pattern	CD		45595-6	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110D2	3	Two+ persons physical assist		Typical pattern	CD		45595-6	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110D2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45595-6	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110E1		Locomotion on unit: self-performance		Typical pattern	CD		45596-4		1.3.6.1.4.1.12009.10.1.70
	G0110E1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45596-4	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110E1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45596-4	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110E1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45596-4	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110E1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45596-4	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110E1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45596-4	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110E1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45596-4	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110E1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45596-4	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110E2		Locomotion on unit: support provided		Typical pattern	CD		45597-2		1.3.6.1.4.1.12009.10.1.160
	G0110E2	0	No setup or physical help from staff		Typical pattern	CD		45597-2	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110E2	1	Setup help only		Typical pattern	CD		45597-2	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110E2	2	One person physical assist		Typical pattern	CD		45597-2	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110E2	3	Two+ persons physical assist		Typical pattern	CD		45597-2	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110E2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45597-2	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110F1		Locomotion off unit: self-performance		Typical pattern	CD		45598-0		1.3.6.1.4.1.12009.10.1.70
	G0110F1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45598-0	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110F1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45598-0	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110F1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45598-0	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110F1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45598-0	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110F1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45598-0	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110F1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45598-0	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110F1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45598-0	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110F2		Locomotion off unit: support provided		Typical pattern	CD		45599-8		1.3.6.1.4.1.12009.10.1.160
	G0110F2	0	No setup or physical help from staff		Typical pattern	CD		45599-8	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110F2	1	Setup help only		Typical pattern	CD		45599-8	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110F2	2	One person physical assist		Typical pattern	CD		45599-8	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110F2	3	Two+ persons physical assist		Typical pattern	CD		45599-8	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110F2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45599-8	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110G1		Dressing: self-performance		Typical pattern	CD		45600-4		1.3.6.1.4.1.12009.10.1.70
	G0110G1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45600-4	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110G1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45600-4	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110G1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45600-4	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110G1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45600-4	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110G1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45600-4	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110G1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45600-4	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110G1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45600-4	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110G2		Dressing: support provided		Typical pattern	CD		45601-2		1.3.6.1.4.1.12009.10.1.160
	G0110G2	0	No setup or physical help from staff		Typical pattern	CD		45601-2	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110G2	1	Setup help only		Typical pattern	CD		45601-2	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110G2	2	One person physical assist		Typical pattern	CD		45601-2	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110G2	3	Two+ persons physical assist		Typical pattern	CD		45601-2	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110G2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45601-2	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110H1		Eating: self-performance		Typical pattern	CD		45602-0		1.3.6.1.4.1.12009.10.1.70
	G0110H1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45602-0	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110H1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45602-0	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110H1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45602-0	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110H1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45602-0	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110H1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45602-0	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110H1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45602-0	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110H1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45602-0	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110H2		Eating: support provided		Typical pattern	CD		45603-8		1.3.6.1.4.1.12009.10.1.160
	G0110H2	0	No setup or physical help from staff		Typical pattern	CD		45603-8	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110H2	1	Setup help only		Typical pattern	CD		45603-8	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110H2	2	One person physical assist		Typical pattern	CD		45603-8	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110H2	3	Two+ persons physical assist		Typical pattern	CD		45603-8	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110H2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45603-8	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110I1		Toilet use: self-performance		Typical pattern	CD		45604-6		1.3.6.1.4.1.12009.10.1.70
	G0110I1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45604-6	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110I1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45604-6	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110I1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45604-6	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110I1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45604-6	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110I1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45604-6	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110I1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45604-6	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110I1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45604-6	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110I2		Toilet use: support provided		Typical pattern	CD		45605-3		1.3.6.1.4.1.12009.10.1.160
	G0110I2	0	No setup or physical help from staff		Typical pattern	CD		45605-3	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110I2	1	Setup help only		Typical pattern	CD		45605-3	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110I2	2	One person physical assist		Typical pattern	CD		45605-3	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110I2	3	Two+ persons physical assist		Typical pattern	CD		45605-3	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110I2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45605-3	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0110J1		Personal hygiene: self-performance		Typical pattern	CD		45606-1		1.3.6.1.4.1.12009.10.1.70
	G0110J1	0	Independent - no help or staff oversight at any time		Typical pattern	CD		45606-1	LA12637-7	1.3.6.1.4.1.12009.10.1.70
	G0110J1	1	Supervision - oversight, encouragement or cueing		Typical pattern	CD		45606-1	LA12638-5	1.3.6.1.4.1.12009.10.1.70
	G0110J1	2	Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance		Typical pattern	CD		45606-1	LA12639-3	1.3.6.1.4.1.12009.10.1.70
	G0110J1	3	Extensive assistance - resident involved in activity, staff provide weight-bearing support		Typical pattern	CD		45606-1	LA12640-1	1.3.6.1.4.1.12009.10.1.70
	G0110J1	4	Total dependence - full staff performance every time during entire 7-day period		Typical pattern	CD		45606-1	LA12641-9	1.3.6.1.4.1.12009.10.1.70
	G0110J1	7	Activity occurred only once or twice - activity did occur but only once or twice.		Typical pattern	CD		45606-1	LA12642-7	1.3.6.1.4.1.12009.10.1.70
	G0110J1	8	Activity did not occur - activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day period		Typical pattern	CD		45606-1	LA12643-5	1.3.6.1.4.1.12009.10.1.70
	G0110J2		Personal hygiene: support provided		Typical pattern	CD		45607-9		1.3.6.1.4.1.12009.10.1.160
	G0110J2	0	No setup or physical help from staff		Typical pattern	CD		45607-9	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0110J2	1	Setup help only		Typical pattern	CD		45607-9	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0110J2	2	One person physical assist		Typical pattern	CD		45607-9	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0110J2	3	Two+ persons physical assist		Typical pattern	CD		45607-9	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0110J2	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45607-9	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0120A		Bathing: self-performance		Typical pattern	CD		45608-7		1.3.6.1.4.1.12009.10.1.161
	G0120A	0	Independent - no help provided		Typical pattern	CD		45608-7	LA110-9	1.3.6.1.4.1.12009.10.1.161
	G0120A	1	Supervision - oversight help only		Typical pattern	CD		45608-7	LA111-7	1.3.6.1.4.1.12009.10.1.161
	G0120A	2	Physical help limited to transfer only		Typical pattern	CD		45608-7	LA112-5	1.3.6.1.4.1.12009.10.1.161
	G0120A	3	Physical help in part of bathing activity		Typical pattern	CD		45608-7	LA113-3	1.3.6.1.4.1.12009.10.1.161
	G0120A	4	Total dependence		Typical pattern	CD		45608-7	LA114-1	1.3.6.1.4.1.12009.10.1.161
	G0120A	8	Activity did not occur during the entire period		Typical pattern	CD		45608-7	LA115-8	1.3.6.1.4.1.12009.10.1.161
	G0120B		Bathing: support provided		Typical pattern	CD		45609-5		1.3.6.1.4.1.12009.10.1.160
	G0120B	0	No setup or physical help from staff		Typical pattern	CD		45609-5	LA105-9	1.3.6.1.4.1.12009.10.1.160
	G0120B	1	Setup help only		Typical pattern	CD		45609-5	LA106-7	1.3.6.1.4.1.12009.10.1.160
	G0120B	2	One person physical assist		Typical pattern	CD		45609-5	LA107-5	1.3.6.1.4.1.12009.10.1.160
	G0120B	3	Two+ persons physical assist		Typical pattern	CD		45609-5	LA108-3	1.3.6.1.4.1.12009.10.1.160
	G0120B	8	ADL activity itself did not occur during entire period		Typical pattern	CD		45609-5	LA109-1	1.3.6.1.4.1.12009.10.1.160
	G0300A		Balance: moving from seated to standing position		Typical pattern	CD		54749-7		1.3.6.1.4.1.12009.10.1.31
	G0300A	0	Steady at all times		Typical pattern	CD		54749-7	LA11031-4	1.3.6.1.4.1.12009.10.1.31
	G0300A	1	Not steady, but able to stabilize without human assistance		Typical pattern	CD		54749-7	LA11032-2	1.3.6.1.4.1.12009.10.1.31
	G0300A	2	Not steady, only able to stabilize with human assistance		Typical pattern	CD		54749-7	LA11033-0	1.3.6.1.4.1.12009.10.1.31
	G0300A	8	Activity did not occur		Typical pattern	CD		54749-7	LA11034-8	1.3.6.1.4.1.12009.10.1.31
	G0300B		Balance: walking (with assistive device if used)		Typical pattern	CD		54750-5		1.3.6.1.4.1.12009.10.1.31
	G0300B	0	Steady at all times		Typical pattern	CD		54750-5	LA11031-4	1.3.6.1.4.1.12009.10.1.31
	G0300B	1	Not steady, but able to stabilize without human assistance		Typical pattern	CD		54750-5	LA11032-2	1.3.6.1.4.1.12009.10.1.31
	G0300B	2	Not steady, only able to stabilize with human assistance		Typical pattern	CD		54750-5	LA11033-0	1.3.6.1.4.1.12009.10.1.31
	G0300B	8	Activity did not occur		Typical pattern	CD		54750-5	LA11034-8	1.3.6.1.4.1.12009.10.1.31
	G0300C		Balance: turning around while walking		Typical pattern	CD		54751-3		1.3.6.1.4.1.12009.10.1.31
	G0300C	0	Steady at all times		Typical pattern	CD		54751-3	LA11031-4	1.3.6.1.4.1.12009.10.1.31
	G0300C	1	Not steady, but able to stabilize without human assistance		Typical pattern	CD		54751-3	LA11032-2	1.3.6.1.4.1.12009.10.1.31
	G0300C	2	Not steady, only able to stabilize with human assistance		Typical pattern	CD		54751-3	LA11033-0	1.3.6.1.4.1.12009.10.1.31
	G0300C	8	Activity did not occur		Typical pattern	CD		54751-3	LA11034-8	1.3.6.1.4.1.12009.10.1.31
	G0300D		Balance: moving on and off toilet		Typical pattern	CD		54752-1		1.3.6.1.4.1.12009.10.1.31
	G0300D	0	Steady at all times		Typical pattern	CD		54752-1	LA11031-4	1.3.6.1.4.1.12009.10.1.31
	G0300D	1	Not steady, but able to stabilize without human assistance		Typical pattern	CD		54752-1	LA11032-2	1.3.6.1.4.1.12009.10.1.31
	G0300D	2	Not steady, only able to stabilize with human assistance		Typical pattern	CD		54752-1	LA11033-0	1.3.6.1.4.1.12009.10.1.31
	G0300D	8	Activity did not occur		Typical pattern	CD		54752-1	LA11034-8	1.3.6.1.4.1.12009.10.1.31
	G0300E		Balance: surface-to-surface transfer		Typical pattern	CD		54753-9		1.3.6.1.4.1.12009.10.1.31
	G0300E	0	Steady at all times		Typical pattern	CD		54753-9	LA11031-4	1.3.6.1.4.1.12009.10.1.31
	G0300E	1	Not steady, but able to stabilize without human assistance		Typical pattern	CD		54753-9	LA11032-2	1.3.6.1.4.1.12009.10.1.31
	G0300E	2	Not steady, only able to stabilize with human assistance		Typical pattern	CD		54753-9	LA11033-0	1.3.6.1.4.1.12009.10.1.31
	G0300E	8	Activity did not occur		Typical pattern	CD		54753-9	LA11034-8	1.3.6.1.4.1.12009.10.1.31
	G0400A		ROM limitation: upper extremity		Typical pattern	CD		54754-7		1.3.6.1.4.1.12009.10.1.36
	G0400A	0	No impairment		Typical pattern	CD		54754-7	LA9606-0	1.3.6.1.4.1.12009.10.1.36
	G0400A	1	Impairment on one side		Typical pattern	CD		54754-7	LA11036-3	1.3.6.1.4.1.12009.10.1.36
	G0400A	2	Impairment on both sides		Typical pattern	CD		54754-7	LA11037-1	1.3.6.1.4.1.12009.10.1.36
	G0400B		ROM limitation: lower extremity		Typical pattern	CD		54755-4		1.3.6.1.4.1.12009.10.1.36
	G0400B	0	No impairment		Typical pattern	CD		54755-4	LA9606-0	1.3.6.1.4.1.12009.10.1.36
	G0400B	1	Impairment on one side		Typical pattern	CD		54755-4	LA11036-3	1.3.6.1.4.1.12009.10.1.36
	G0400B	2	Impairment on both sides		Typical pattern	CD		54755-4	LA11037-1	1.3.6.1.4.1.12009.10.1.36
	G0600A		Mobility devices: cane/crutch		Multiple response pattern	BL		54756-2
	G0600B		Mobility devices: walker		Multiple response pattern	BL		54757-0
	G0600C		Mobility devices: wheelchair (manual or electric)		Multiple response pattern	BL		54758-8
	G0600D		Mobility devices: limb prosthesis		Multiple response pattern	BL		54759-6
	G0600Z		Mobility devices: none of the above		Multiple response pattern	BL		54760-4
	G0900A		Resident believes capable of increased independ		Typical pattern	CD		55123-4		1.3.6.1.4.1.12009.10.1.58
	G0900A	0	No		Typical pattern	CD		55123-4	LA32-8	1.3.6.1.4.1.12009.10.1.58
	G0900A	1	Yes		Typical pattern	CD		55123-4	LA33-6	1.3.6.1.4.1.12009.10.1.58
	G0900A	9	Unable to determine		Typical pattern	CD		55123-4	LA11137-9	1.3.6.1.4.1.12009.10.1.58
	G0900B		Staff believes res capable of increased independ		Typical pattern	CD		45613-7		1.3.6.1.4.1.12009.10.1.62
	G0900B	0	No		Typical pattern	CD		45613-7	LA32-8	1.3.6.1.4.1.12009.10.1.62
	G0900B	1	Yes		Typical pattern	CD		45613-7	LA33-6	1.3.6.1.4.1.12009.10.1.62

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
H			Bladder and Bowel
	H0100A		Appliances: indwelling catheter		Multiple response pattern	BL		54762-0
	H0100B		Appliances: external catheter		Multiple response pattern	BL		54763-8
	H0100C		Appliances: ostomy		Multiple response pattern	BL		54764-6
	H0100D		Appliances: intermittent catheterization		Multiple response pattern	BL		54765-3
	H0100Z		Appliances: none of the above		Multiple response pattern	BL		54766-1
	H0200A		Urinary toileting program: has been attempted		Typical pattern	CD		54767-9		1.3.6.1.4.1.12009.10.1.58
	H0200A	0	No		Typical pattern	CD		54767-9	LA32-8	1.3.6.1.4.1.12009.10.1.58
	H0200A	1	Yes		Typical pattern	CD		54767-9	LA33-6	1.3.6.1.4.1.12009.10.1.58
	H0200A	9	Unable to determine		Typical pattern	CD		54767-9	LA11137-9	1.3.6.1.4.1.12009.10.1.58
	H0200B		Urinary toileting program: response		Typical pattern	CD		54768-7		1.3.6.1.4.1.12009.10.1.30
	H0200B	0	No improvement		Typical pattern	CD		54768-7	LA11038-9	1.3.6.1.4.1.12009.10.1.30
	H0200B	1	Decreased wetness		Typical pattern	CD		54768-7	LA11039-7	1.3.6.1.4.1.12009.10.1.30
	H0200B	2	Completely dry (continent)		Typical pattern	CD		54768-7	LA11040-5	1.3.6.1.4.1.12009.10.1.30
	H0200B	9	Unable to determine or trial in progress		Typical pattern	CD		54768-7	LA11041-3	1.3.6.1.4.1.12009.10.1.30
	H0200C		Urinary toileting program: current program/trial		Typical pattern	CD		54769-5		1.3.6.1.4.1.12009.10.1.62
	H0200C	0	No		Typical pattern	CD		54769-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	H0200C	1	Yes		Typical pattern	CD		54769-5	LA33-6	1.3.6.1.4.1.12009.10.1.62
	H0300		Urinary continence		Typical pattern	CD		54770-3		1.3.6.1.4.1.12009.10.1.29
	H0300	0	Always continent		Typical pattern	CD		54770-3	LA11042-1	1.3.6.1.4.1.12009.10.1.29
	H0300	1	Occasionally incontinent (less than 7 episodes of incontinence)		Typical pattern	CD		54770-3	LA11043-9	1.3.6.1.4.1.12009.10.1.29
	H0300	2	Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)		Typical pattern	CD		54770-3	LA11044-7	1.3.6.1.4.1.12009.10.1.29
	H0300	3	Always incontinent (no episodes of continent voiding)		Typical pattern	CD		54770-3	LA11045-4	1.3.6.1.4.1.12009.10.1.29
	H0300	9	Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for entire 7 days		Typical pattern	CD		54770-3	LA11046-2	1.3.6.1.4.1.12009.10.1.29
	H0400		Bowel continence		Typical pattern	CD		54771-1		1.3.6.1.4.1.12009.10.1.28
	H0400	0	Always continent		Typical pattern	CD		54771-1	LA11042-1	1.3.6.1.4.1.12009.10.1.28
	H0400	1	Occasionally incontinent (one episode of bowel incontinence)		Typical pattern	CD		54771-1	LA11048-8	1.3.6.1.4.1.12009.10.1.28
	H0400	2	Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)		Typical pattern	CD		54771-1	LA11049-6	1.3.6.1.4.1.12009.10.1.28
	H0400	3	Always incontinent (no episodes of continent bowel movements)		Typical pattern	CD		54771-1	LA11050-4	1.3.6.1.4.1.12009.10.1.28
	H0400	9	Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days		Typical pattern	CD		54771-1	LA11051-2	1.3.6.1.4.1.12009.10.1.28
	H0500		Bowel toileting program being used		Typical pattern	CD		54772-9		1.3.6.1.4.1.12009.10.1.62
	H0500	0	No		Typical pattern	CD		54772-9	LA32-8	1.3.6.1.4.1.12009.10.1.62
	H0500	1	Yes		Typical pattern	CD		54772-9	LA33-6	1.3.6.1.4.1.12009.10.1.62
	H0600		Constipation		Typical pattern	CD		54773-7		1.3.6.1.4.1.12009.10.1.62
	H0600	0	No		Typical pattern	CD		54773-7	LA32-8	1.3.6.1.4.1.12009.10.1.62
	H0600	1	Yes		Typical pattern	CD		54773-7	LA33-6	1.3.6.1.4.1.12009.10.1.62

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
I			Active Disease Diagnosis
	I0100		Cancer (with or without metastasis)		Multiple response pattern	BL		54774-5
	I0200		Anemia		Multiple response pattern	BL		54775-2
	I0300		Atrial fibrillation and other dysrhythmias		Multiple response pattern	BL		54776-0
	I0400		Coronary artery disease (CAD)		Multiple response pattern	BL		54777-8
	I0500		Deep venous thrombosis (DVT), PE, or PTE		Multiple response pattern	BL		54778-6
	I0600		Heart failure		Multiple response pattern	BL		54779-4
	I0700		Hypertension		Multiple response pattern	BL		54780-2
	I0800		Orthostatic hypotension		Multiple response pattern	BL		54781-0
	I0900		Peripheral vascular disease (PVD) or PAD		Multiple response pattern	BL		54782-8
	I1100		Cirrhosis		Multiple response pattern	BL		54783-6
	I1200		Gastroesophageal reflux disease (GERD) or ulcer		Multiple response pattern	BL		54784-4
	I1300		Ulcerative colitis, Crohn’s, inflam bowel disease		Multiple response pattern	BL		54785-1
	I1400		Benign prostatic hyperplasia (BPH)		Multiple response pattern	BL		54786-9
	I1500		Renal insufficiency, renal failure, ESRD		Multiple response pattern	BL		54787-7
	I1550		Neurogenic bladder		Multiple response pattern	BL		58111-6
	I1650		Obstructive uropathy		Multiple response pattern	BL		58112-4
	I1700		Multidrug resistant organism (MDRO)		Multiple response pattern	BL		58109-0
	I2000		Pneumonia		Multiple response pattern	BL		54790-1
	I2100		Septicemia		Multiple response pattern	BL		54791-9
	I2200		Tuberculosis		Multiple response pattern	BL		54792-7
	I2300		Urinary tract infection (UTI) (LAST 30 DAYS)		Multiple response pattern	BL		54793-5
	I2400		Viral hepatitis (includes type A, B, C, D, and E)		Multiple response pattern	BL		54794-3
	I2500		Wound infection (other than foot)		Multiple response pattern	BL		54965-9
	I2900		Diabetes mellitus (DM)		Multiple response pattern	BL		54795-0
	I3100		Hyponatremia		Multiple response pattern	BL		54796-8
	I3200		Hyperkalemia		Multiple response pattern	BL		54797-6
	I3300		Hyperlipidemia (e.g.,  hypercholesterolemia)		Multiple response pattern	BL		54798-4
	I3400		Thyroid disorder		Multiple response pattern	BL		54799-2
	I3700		Arthritis		Multiple response pattern	BL		54800-8
	I3800		Osteoporosis		Multiple response pattern	BL		54801-6
	I3900		Hip fracture		Multiple response pattern	BL		54802-4
	I4000		Other fracture		Multiple response pattern	BL		54803-2
	I4200		Alzheimer's disease		Multiple response pattern	BL		54804-0
	I4300		Aphasia		Multiple response pattern	BL		54805-7
	I4400		Cerebral palsy		Multiple response pattern	BL		54806-5
	I4500		Cerebrovascular accident (CVA), TIA, or stroke		Multiple response pattern	BL		54807-3
	I4800		Dementia		Multiple response pattern	BL		54808-1
	I4900		Hemiplegia or hemiparesis		Multiple response pattern	BL		54809-9
	I5000		Paraplegia		Multiple response pattern	BL		54810-7
	I5100		Quadriplegia		Multiple response pattern	BL		54811-5
	I5200		Multiple sclerosis		Multiple response pattern	BL		54812-3
	I5250		Huntington's disease		Multiple response pattern	BL		58113-2
	I5300		Parkinson's disease		Multiple response pattern	BL		54813-1
	I5350		Tourette's syndrome		Multiple response pattern	BL		58114-0
	I5400		Seizure disorder or epilepsy		Multiple response pattern	BL		54814-9
	I5500		Traumatic brain injury (TBI)		Multiple response pattern	BL		54815-6
	I5600		Malnutrition (protein, calorie), risk of malnutrit		Multiple response pattern	BL		54816-4
	I5700		Anxiety disorder		Multiple response pattern	BL		54817-2
	I5800		Depression (other than bipolar)		Multiple response pattern	BL		54818-0
	I5900		Manic depression (bipolar disease)		Multiple response pattern	BL		54819-8
	I5950		Psychotic disorder (other than schizophrenia)		Multiple response pattern	BL		58115-7
	I6000		Schizophrenia		Multiple response pattern	BL		54820-6
	I6100		Post-traumatic stress disorder (PTSD)		Multiple response pattern	BL		54821-4
	I6200		Asthma (COPD) or chronic lung disease		Multiple response pattern	BL		54822-2
	I6300		Respiratory failure		Multiple response pattern	BL		58116-5
	I6500		Cataracts, glaucoma, or macular degeneration		Multiple response pattern	BL		54823-0
	I7900		None of above active diseases within last 7 days		Multiple response pattern	BL		54824-8
	I8000A		Additional active ICD diagnosis 1		Other response data type pattern	CD		54546-7
	I8000B		Additional active ICD diagnosis 2		Other response data type pattern	CD		54547-5
	I8000C		Additional active ICD diagnosis 3		Other response data type pattern	CD		54548-3
	I8000D		Additional active ICD diagnosis 4		Other response data type pattern	CD		54549-1
	I8000E		Additional active ICD diagnosis 5		Other response data type pattern	CD		54550-9
	I8000F		Additional active ICD diagnosis 6		Other response data type pattern	CD		54551-7
	I8000G		Additional active ICD diagnosis 7		Other response data type pattern	CD		54552-5
	I8000H		Additional active ICD diagnosis 8		Other response data type pattern	CD		54553-3
	I8000I		Additional active ICD diagnosis 9		Other response data type pattern	CD		54554-1
	I8000J		Additional active ICD diagnosis 10		Other response data type pattern	CD		54555-8

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
J			Health Conditions
	J0100A		Pain: been on scheduled pain med regimen		Typical pattern	CD		54825-5		1.3.6.1.4.1.12009.10.1.62
	J0100A	0	No		Typical pattern	CD		54825-5	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J0100A	1	Yes		Typical pattern	CD		54825-5	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J0100B		Pain: received PRN pain medications		Typical pattern	CD		54826-3		1.3.6.1.4.1.12009.10.1.62
	J0100B	0	No		Typical pattern	CD		54826-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J0100B	1	Yes		Typical pattern	CD		54826-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J0100C		Pain: received non-medication intervention		Typical pattern	CD		54827-1		1.3.6.1.4.1.12009.10.1.62
	J0100C	0	No		Typical pattern	CD		54827-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J0100C	1	Yes		Typical pattern	CD		54827-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J0200		Should pain assessment interview be conducted		Typical pattern	CD		54828-9		1.3.6.1.4.1.12009.10.1.2
	J0200	0	No (resident rarely/never understood)		Typical pattern	CD		54828-9	LA11150-2	1.3.6.1.4.1.12009.10.1.2
	J0200	1	Yes		Typical pattern	CD		54828-9	LA33-6	1.3.6.1.4.1.12009.10.1.2
	J0300		Res pain interview: presence		Typical pattern	CD		54829-7		1.3.6.1.4.1.12009.10.1.27
	J0300	0	No		Typical pattern	CD		54829-7	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J0300	1	Yes		Typical pattern	CD		54829-7	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J0300	9	Unable to answer		Typical pattern	CD		54829-7	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J0400		Res pain interview: frequency		Typical pattern	CD		54830-5		1.3.6.1.4.1.12009.10.1.26
	J0400	1	Almost constantly		Typical pattern	CD		54830-5	LA11055-3	1.3.6.1.4.1.12009.10.1.26
	J0400	2	Frequently		Typical pattern	CD		54830-5	LA6482-9	1.3.6.1.4.1.12009.10.1.26
	J0400	3	Occasionally		Typical pattern	CD		54830-5	LA6483-7	1.3.6.1.4.1.12009.10.1.26
	J0400	4	Rarely		Typical pattern	CD		54830-5	LA10066-1	1.3.6.1.4.1.12009.10.1.26
	J0400	9	Unable to answer		Typical pattern	CD		54830-5	LA11054-6	1.3.6.1.4.1.12009.10.1.26
	J0500A		Res pain interview: made it hard to sleep		Typical pattern	CD		54831-3		1.3.6.1.4.1.12009.10.1.27
	J0500A	0	No		Typical pattern	CD		54831-3	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J0500A	1	Yes		Typical pattern	CD		54831-3	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J0500A	9	Unable to answer		Typical pattern	CD		54831-3	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J0500B		Res pain interview: limited daily activities		Typical pattern	CD		54832-1		1.3.6.1.4.1.12009.10.1.27
	J0500B	0	No		Typical pattern	CD		54832-1	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J0500B	1	Yes		Typical pattern	CD		54832-1	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J0500B	9	Unable to answer		Typical pattern	CD		54832-1	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J0600A		Res pain interview: intensity rating scale		Other response data type pattern	INT		54833-9
	J0600B		Res pain interview: verbal descriptor scale		Typical pattern	CD		54834-7		1.3.6.1.4.1.12009.10.1.25
	J0600B	1	Mild		Typical pattern	CD		54834-7	LA6752-5	1.3.6.1.4.1.12009.10.1.25
	J0600B	2	Moderate		Typical pattern	CD		54834-7	LA6751-7	1.3.6.1.4.1.12009.10.1.25
	J0600B	3	Severe		Typical pattern	CD		54834-7	LA6750-9	1.3.6.1.4.1.12009.10.1.25
	J0600B	4	Very severe, horrible		Typical pattern	CD		54834-7	LA11063-7	1.3.6.1.4.1.12009.10.1.25
	J0600B	9	Unable to answer		Typical pattern	CD		54834-7	LA11054-6	1.3.6.1.4.1.12009.10.1.25
	J0700		Should staff assessment for pain be conducted		Typical pattern	CD		58117-3		1.3.6.1.4.1.12009.10.1.62
	J0700	0	No (J0400=1 thru 4)		Typical pattern	CD		58117-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J0700	1	Yes (J0200=0 or J0300=9 or J0400=9)		Typical pattern	CD		58117-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J0800A		Staff pain asmt: non-verbal sounds		Multiple response pattern	BL		54835-4
	J0800B		Staff pain asmt: vocal complaints of pain		Multiple response pattern	BL		54836-2
	J0800C		Staff pain asmt: facial expressions		Multiple response pattern	BL		54837-0
	J0800D		Staff pain asmt: protective movements/postures		Multiple response pattern	BL		54838-8
	J0800Z		Staff pain asmt: none of these signs observed		Multiple response pattern	BL		54839-6
	J0850		Staff pain asmt: frequency of pain		Typical pattern	CD		58118-1		1.3.6.1.4.1.12009.10.1.71
	J0850	1	Indicators of pain or possible pain observed 1 to 2 days		Typical pattern	CD		58118-1	LA12645-0	1.3.6.1.4.1.12009.10.1.71
	J0850	2	Indicators of pain or possible pain observed 3 to 4 days		Typical pattern	CD		58118-1	LA12646-8	1.3.6.1.4.1.12009.10.1.71
	J0850	3	Indicators of possible pain observed daily		Typical pattern	CD		58118-1	LA12647-6	1.3.6.1.4.1.12009.10.1.71
	J1100A		Short breath/trouble breathing: with exertion		Multiple response pattern	BL		54841-2
	J1100B		Short breath/trouble breathing: sitting at rest		Multiple response pattern	BL		54842-0
	J1100C		Short breath/trouble breathing: lying flat		Multiple response pattern	BL		54843-8
	J1100Z		Short breath/trouble breathing: none of above		Multiple response pattern	BL		54844-6
	J1300		Current tobacco use		Typical pattern	CD		54845-3		1.3.6.1.4.1.12009.10.1.62
	J1300	0	No		Typical pattern	CD		54845-3	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J1300	1	Yes		Typical pattern	CD		54845-3	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J1400		Prognosis: life expectancy of less than 6 months		Typical pattern	CD		54846-1		1.3.6.1.4.1.12009.10.1.62
	J1400	0	No		Typical pattern	CD		54846-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J1400	1	Yes		Typical pattern	CD		54846-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J1550A		Problem conditions: fever		Multiple response pattern	BL		45701-0
	J1550B		Problem conditions: vomiting		Multiple response pattern	BL		45708-5
	J1550C		Problem conditions: dehydrated		Multiple response pattern	BL		45696-2
	J1550D		Problem conditions: internal bleeding		Multiple response pattern	BL		45703-6
	J1550Z		Problem conditions: none of the above		Multiple response pattern	BL		54848-7
	J1700A		Fall history: fall during month before admission		Typical pattern	CD		54850-3		1.3.6.1.4.1.12009.10.1.27
	J1700A	0	No		Typical pattern	CD		54850-3	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J1700A	1	Yes		Typical pattern	CD		54850-3	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J1700A	9	Unable to determine		Typical pattern	CD		54850-3	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J1700B		Fall history: fall 2-6 months before admission		Typical pattern	CD		54851-1		1.3.6.1.4.1.12009.10.1.27
	J1700B	0	No		Typical pattern	CD		54851-1	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J1700B	1	Yes		Typical pattern	CD		54851-1	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J1700B	9	Unable to determine		Typical pattern	CD		54851-1	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J1700C		Fall history: fracture from fall 6 month pre admit		Typical pattern	CD		54852-9		1.3.6.1.4.1.12009.10.1.27
	J1700C	0	No		Typical pattern	CD		54852-9	LA32-8	1.3.6.1.4.1.12009.10.1.27
	J1700C	1	Yes		Typical pattern	CD		54852-9	LA33-6	1.3.6.1.4.1.12009.10.1.27
	J1700C	9	Unable to determine		Typical pattern	CD		54852-9	LA11054-6	1.3.6.1.4.1.12009.10.1.27
	J1800		Falls since admit/prior asmt: any falls		Typical pattern	CD		54853-7		1.3.6.1.4.1.12009.10.1.62
	J1800	0	No		Typical pattern	CD		54853-7	LA32-8	1.3.6.1.4.1.12009.10.1.62
	J1800	1	Yes		Typical pattern	CD		54853-7	LA33-6	1.3.6.1.4.1.12009.10.1.62
	J1900A		Falls since admit/prior asmt: no injury		Typical pattern	CD		54855-2		1.3.6.1.4.1.12009.10.1.22
	J1900A	0	None		Typical pattern	CD		54855-2	LA137-2	1.3.6.1.4.1.12009.10.1.22
	J1900A	1	One		Typical pattern	CD		54855-2	LA6306-0	1.3.6.1.4.1.12009.10.1.22
	J1900A	2	Two or more		Typical pattern	CD		54855-2	LA11073-6	1.3.6.1.4.1.12009.10.1.22
	J1900B		Falls since admit/prior asmt: injury (not major)		Typical pattern	CD		54856-0		1.3.6.1.4.1.12009.10.1.22
	J1900B	0	None		Typical pattern	CD		54856-0	LA137-2	1.3.6.1.4.1.12009.10.1.22
	J1900B	1	One		Typical pattern	CD		54856-0	LA6306-0	1.3.6.1.4.1.12009.10.1.22
	J1900B	2	Two or more		Typical pattern	CD		54856-0	LA11073-6	1.3.6.1.4.1.12009.10.1.22
	J1900C		Falls since admit/prior asmt: major injury		Typical pattern	CD		54857-8		1.3.6.1.4.1.12009.10.1.22
	J1900C	0	None		Typical pattern	CD		54857-8	LA137-2	1.3.6.1.4.1.12009.10.1.22
	J1900C	1	One		Typical pattern	CD		54857-8	LA6306-0	1.3.6.1.4.1.12009.10.1.22
	J1900C	2	Two or more		Typical pattern	CD		54857-8	LA11073-6	1.3.6.1.4.1.12009.10.1.22

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
K			Swallowing/Nutritional Status
	K0100A		Swallow disorder: loss liquids/ solids from mouth		Multiple response pattern	BL		54858-6
	K0100B		Swallow disorder: holds food in mouth/cheeks		Multiple response pattern	BL		54859-4
	K0100C		Swallow disorder: cough/ choke with meals/meds		Multiple response pattern	BL		54860-2
	K0100D		Swallow disorder: difficulty or pain swallowing		Multiple response pattern	BL		54861-0
	K0100Z		Swallow disorder: none of the above		Multiple response pattern	BL		54862-8
	K0200A		Height (in inches)		Other response data type pattern	PQ	[in_i]	3137-7
	K0200B		Weight (in pounds)		Other response data type pattern	PQ	[lb_av]	3141-9
	K0300		Weight loss		Typical pattern	CD		54863-6		1.3.6.1.4.1.12009.10.1.21
	K0300	0	No, or unknown		Typical pattern	CD		54863-6	LA11074-4	1.3.6.1.4.1.12009.10.1.21
	K0300	1	Yes, on physician - prescribed weight - loss regimen		Typical pattern	CD		54863-6	LA11075-1	1.3.6.1.4.1.12009.10.1.21
	K0300	2	Yes, not on physician - prescribed weight - loss regimen		Typical pattern	CD		54863-6	LA11076-9	1.3.6.1.4.1.12009.10.1.21
	K0500A		Nutritional approaches: parenteral /IV feeding		Multiple response pattern	BL		54864-4
	K0500B		Nutritional approaches: feeding tube		Multiple response pattern	BL		54865-1
	K0500C		Nutritional approaches: mechanically altered diet		Multiple response pattern	BL		54866-9
	K0500D		Nutritional approaches: therapeutic diet		Multiple response pattern	BL		54867-7
	K0500Z		Nutritional approaches: none of the above		Multiple response pattern	BL		54868-5
	K0700A		Proportion total calories via parenteral/tube feed		Typical pattern	CD		54897-4		1.3.6.1.4.1.12009.10.1.20
	K0700A	1	25% or less		Typical pattern	CD		54897-4	LA11077-7	1.3.6.1.4.1.12009.10.1.20
	K0700A	2	26-50%		Typical pattern	CD		54897-4	LA11078-5	1.3.6.1.4.1.12009.10.1.20
	K0700A	3	51% or more		Typical pattern	CD		54897-4	LA11079-3	1.3.6.1.4.1.12009.10.1.20
	K0700B		Average fluid intake per day by IV or tube		Typical pattern	CD		54869-3		1.3.6.1.4.1.12009.10.1.19
	K0700B	1	500 cc/day or less		Typical pattern	CD		54869-3	LA11080-1	1.3.6.1.4.1.12009.10.1.19
	K0700B	2	501 cc/day or more		Typical pattern	CD		54869-3	LA11081-9	1.3.6.1.4.1.12009.10.1.19

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
L			Oral/Dental Status
	L0200A		Dental: broken or loosely fitting denture		Multiple response pattern	BL		54871-9
	L0200B		Dental: no natural teeth or tooth fragment(s)		Multiple response pattern	BL		54872-7
	L0200C		Dental: abnormal mouth tissue		Multiple response pattern	BL		54873-5
	L0200D		Dental: cavity or broken natural teeth		Multiple response pattern	BL		54874-3
	L0200E		Dental: inflamed/bleeding gums or loose teeth		Multiple response pattern	BL		54875-0
	L0200F		Dental: pain, discomfort, difficulty chewing		Multiple response pattern	BL		54876-8
	L0200G		Dental: unable to examine		Multiple response pattern	BL		58119-9
	L0200Z		Dental: none of the above		Multiple response pattern	BL		54877-6

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
M			Skin Conditions
	M0100A		Risk determination: has ulcer, scar, or dressing		Multiple response pattern	BL		54878-4
	M0100B		Risk determination: formal assessment		Multiple response pattern	BL		54879-2
	M0100C		Risk determination: clinical assessment		Multiple response pattern	BL		54880-0
	M0100Z		Risk determination: none of the above		Multiple response pattern	BL		54881-8
	M0150		Is resident at risk of developing pressure ulcer		Typical pattern	CD		54882-6		1.3.6.1.4.1.12009.10.1.62
	M0150	0	No		Typical pattern	CD		54882-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	M0150	1	Yes		Typical pattern	CD		54882-6	LA33-6	1.3.6.1.4.1.12009.10.1.62
	M0210		Resident has Stage 1 or higher pressure ulcers		Typical pattern	CD		58214-8		1.3.6.1.4.1.12009.10.1.62
	M0210	0	No		Typical pattern	CD		58214-8	LA32-8	1.3.6.1.4.1.12009.10.1.62
	M0210	1	Yes		Typical pattern	CD		58214-8	LA33-6	1.3.6.1.4.1.12009.10.1.62
	M0300A		Stage 1 pressure ulcers: number present		Other response data type pattern	INT		54884-2
	M0300B1		Stage 2 pressure ulcers: number present		Other response data type pattern	INT		55124-2
	M0300B2		Stage 2 pressure ulcers: number at admit/reentry		Other response data type pattern	INT		54886-7
	M0300B3		Stage 2 pressure ulcers: date of oldest		Other response data type pattern	TS		58123-1
	M0300C1		Stage 3 pressure ulcers: number present		Other response data type pattern	INT		55125-9
	M0300C2		Stage 3 pressure ulcers: number at admit/reentry		Other response data type pattern	INT		54887-5
	M0300D1		Stage 4 pressure ulcers: number present		Other response data type pattern	INT		55126-7
	M0300D2		Stage 4 pressure ulcers: number at admit/reentry		Other response data type pattern	INT		54890-9
	M0300E1		Unstaged due to dressing: number present		Other response data type pattern	INT		54893-3
	M0300E2		Unstaged due to dressing: number at admit/reentry		Other response data type pattern	INT		54894-1
	M0300F1		Unstaged slough/eschar: number present		Other response data type pattern	INT		54946-9
	M0300F2		Unstaged slough/eschar: number at admit/reentry		Other response data type pattern	INT		54947-7
	M0300G1		Unstageable - deep tissue: number present		Other response data type pattern	INT		54950-1
	M0300G2		Unstageable - deep tissue: number at admit/reentry		Other response data type pattern	INT		54951-9
	M0610A		Stage 3 or 4 pressure ulcer longest length		Other response data type pattern	PQ	cm	52728-3
	M0610B		Stage 3 or 4 pressure ulcer width (same ulcer)		Other response data type pattern	PQ	cm	52729-1
	M0610C		Stage 3 or 4 pressure ulcer depth (same ulcer)		Other response data type pattern	PQ	cm	57228-9
	M0700		Tissue type for ulcer at most advanced stage		Typical pattern	CD		55073-1		1.3.6.1.4.1.12009.10.1.18
	M0700	1	Epithelial Tissue - new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin.		Typical pattern	CD		55073-1	LA11082-7	1.3.6.1.4.1.12009.10.1.18
	M0700	2	Granulation Tissue - pink or red tissue with shiny, moist, granular appearance		Typical pattern	CD		55073-1	LA11083-5	1.3.6.1.4.1.12009.10.1.18
	M0700	3	Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous		Typical pattern	CD		55073-1	LA11084-3	1.3.6.1.4.1.12009.10.1.18
	M0700	4	Necrotic Tissue (Eschar) - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin.		Typical pattern	CD		55073-1	LA11085-0	1.3.6.1.4.1.12009.10.1.18
	M0800A		Worsened since prior asmt: Stage 2 pressure ulcers		Other response data type pattern	INT		54953-5
	M0800B		Worsened since prior asmt: Stage 3 pressure ulcers		Other response data type pattern	INT		54954-3
	M0800C		Worsened since prior asmt: Stage 4 pressure ulcers		Other response data type pattern	INT		54955-0
	M0900A		Pressure ulcers on prior assessment		Typical pattern	CD		54957-6		1.3.6.1.4.1.12009.10.1.62
	M0900A	0	No		Typical pattern	CD		54957-6	LA32-8	1.3.6.1.4.1.12009.10.1.62
	M0900A	1	Yes		Typical pattern	CD		54957-6	LA33-6	1.3.6.1.4.1.12009.10.1.62
	M0900B		Healed pressure ulcers: Stage 2		Other response data type pattern	INT		54958-4
	M0900C		Healed pressure ulcers: Stage 3		Other response data type pattern	INT		54959-2
	M0900D		Healed pressure ulcers: Stage 4		Other response data type pattern	INT		54960-0
	M1030		Number of venous and arterial ulcers		Other response data type pattern	INT		54970-9
	M1040A		Other skin probs: infection of the foot		Multiple response pattern	BL		58228-8
	M1040B		Other skin probs: diabetic foot ulcer(s)		Multiple response pattern	BL		54963-4
	M1040C		Other skin probs: other open lesion(s) on the foot		Multiple response pattern	BL		58125-6
	M1040D		Other skin probs: lesions not ulcers, rashes, cuts		Multiple response pattern	BL		54967-5
	M1040E		Other skin probs: surgical wound(s)		Multiple response pattern	BL		54966-7
	M1040F		Other skin probs: burn(s) (second or third degree)		Multiple response pattern	BL		54968-3
	M1040Z		Other skin probs: none of the above		Multiple response pattern	BL		54969-1
	M1200A		Skin/ulcer treat: pressure reduce device for chair		Multiple response pattern	BL		54972-5
	M1200B		Skin/ulcer treat: pressure reducing device for bed		Multiple response pattern	BL		54973-3
	M1200C		Skin/ulcer treat: turning/ repositioning		Multiple response pattern	BL		54974-1
	M1200D		Skin/ulcer treat: nutrition/ hydration		Multiple response pattern	BL		54975-8
	M1200E		Skin/ulcer treat: ulcer care		Multiple response pattern	BL		54976-6
	M1200F		Skin/ulcer treat: surgical wound care		Multiple response pattern	BL		54977-4
	M1200G		Skin/ulcer treat: application of dressings		Multiple response pattern	BL		54978-2
	M1200H		Skin/ulcer treat: apply ointments/medications		Multiple response pattern	BL		54979-0
	M1200I		Skin/ulcer treat: apply dressings to feet		Multiple response pattern	BL		54980-8
	M1200Z		Skin/ulcer treat: none of the above		Multiple response pattern	BL		54981-6

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
N			Medications
	N0300		Number of days injectable medications received		Other response data type pattern	PQ	d	54982-4
	N0350A		Insulin: insulin injections		Other response data type pattern	PQ	d	58127-2
	N0350B		Insulin: orders for insulin		Other response data type pattern	PQ	d	58128-0
	N0400A		Medications: antipsychotic		Multiple response pattern	BL		54984-0
	N0400B		Medications: antianxiety		Multiple response pattern	BL		54985-7
	N0400C		Medications: antidepressant		Multiple response pattern	BL		54986-5
	N0400D		Medications: hypnotic		Multiple response pattern	BL		54987-3
	N0400E		Medications: anticoagulant		Multiple response pattern	BL		54988-1
	N0400F		Medications: antibiotic		Multiple response pattern	BL		58129-8
	N0400G		Medications: diuretic		Multiple response pattern	BL		58130-6
	N0400Z		Medications: none of the above		Multiple response pattern	BL		54989-9

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
O			Special Treatments and Procedures
	O0100A1		Treatment: chemotherapy - while not resident		Multiple response pattern	BL		54992-3
	O0100A2		Treatment: chemotherapy - while resident		Multiple response pattern	BL		54993-1
	O0100B1		Treatment: radiation - while not resident		Multiple response pattern	BL		54994-9
	O0100B2		Treatment: radiation - while resident		Multiple response pattern	BL		54995-6
	O0100C1		Treatment: oxygen therapy - while not resident		Multiple response pattern	BL		54996-4
	O0100C2		Treatment: oxygen therapy - while resident		Multiple response pattern	BL		54997-2
	O0100D1		Treatment: suctioning - while not resident		Multiple response pattern	BL		54998-0
	O0100D2		Treatment: suctioning - while resident		Multiple response pattern	BL		54999-8
	O0100E1		Treatment: tracheostomy care - while not resident		Multiple response pattern	BL		55000-4
	O0100E2		Treatment: tracheostomy care - while resident		Multiple response pattern	BL		55001-2
	O0100F1		Treatment: vent/respirator - while not resident		Multiple response pattern	BL		55002-0
	O0100F2		Treatment: vent/respirator - while resident		Multiple response pattern	BL		55003-8
	O0100G1		Treatment: BiPAP/CPAP - while not resident		Multiple response pattern	BL		55004-6
	O0100G2		Treatment: BIPAP/CPAP - while resident		Multiple response pattern	BL		55005-3
	O0100H1		Treatment: IV medications - while not resident		Multiple response pattern	BL		55006-1
	O0100H2		Treatment: IV medications - while resident		Multiple response pattern	BL		55007-9
	O0100I1		Treatment: transfusions - while not resident		Multiple response pattern	BL		55008-7
	O0100I2		Treatment: transfusions - while resident		Multiple response pattern	BL		55009-5
	O0100J1		Treatment: dialysis - while not resident		Multiple response pattern	BL		55010-3
	O0100J2		Treatment: dialysis - while resident		Multiple response pattern	BL		55011-1
	O0100K1		Treatment: hospice care - while not resident		Multiple response pattern	BL		55012-9
	O0100K2		Treatment: hospice care - while resident		Multiple response pattern	BL		55013-7
	O0100L2		Treatment: respite care - while resident		Multiple response pattern	BL		55015-2
	O0100M1		Treatment: isolate/quarantine - while not resident		Multiple response pattern	BL		55016-0
	O0100M2		Treatment: isolate/quarantine - while resident		Multiple response pattern	BL		55017-8
	O0100Z1		Treatment: none of above - while not resident		Multiple response pattern	BL		59374-9
	O0100Z2		Treatment: none of above - while resident		Multiple response pattern	BL		59373-1
	O0250A		Was influenza vaccine received		Typical pattern	CD		55019-4		1.3.6.1.4.1.12009.10.1.62
	O0250A	0	No		Typical pattern	CD		55019-4	LA32-8	1.3.6.1.4.1.12009.10.1.62
	O0250A	1	Yes		Typical pattern	CD		55019-4	LA33-6	1.3.6.1.4.1.12009.10.1.62
	O0250B		Date influenza vaccine received.		Other response data type pattern	TS		58131-4
	O0250C		If influenza vaccine not received, state reason		Typical pattern	CD		55020-2		1.3.6.1.4.1.12009.10.1.16
	O0250C	1	Resident not in facility during this year's flu season		Typical pattern	CD		55020-2	LA12666-6	1.3.6.1.4.1.12009.10.1.16
	O0250C	2	Received outside of this facility		Typical pattern	CD		55020-2	LA184-4	1.3.6.1.4.1.12009.10.1.16
	O0250C	3	Not eligible - medical contraindication		Typical pattern	CD		55020-2	LA11091-8	1.3.6.1.4.1.12009.10.1.16
	O0250C	4	Offered and declined		Typical pattern	CD		55020-2	LA186-9	1.3.6.1.4.1.12009.10.1.16
	O0250C	5	Not offered		Typical pattern	CD		55020-2	LA187-7	1.3.6.1.4.1.12009.10.1.16
	O0250C	6	Inability to obtain vaccine due to a declared shortage		Typical pattern	CD		55020-2	LA12156-8	1.3.6.1.4.1.12009.10.1.16
	O0250C	9	None of the above		Typical pattern	CD		55020-2	LA9-3	1.3.6.1.4.1.12009.10.1.16
	O0300A		Is pneumococcal vaccination up to date		Typical pattern	CD		55022-8		1.3.6.1.4.1.12009.10.1.62
	O0300A	0	No		Typical pattern	CD		55022-8	LA32-8	1.3.6.1.4.1.12009.10.1.62
	O0300A	1	Yes		Typical pattern	CD		55022-8	LA33-6	1.3.6.1.4.1.12009.10.1.62
	O0300B		If pneumococcal vacc not received, state reason		Typical pattern	CD		55023-6		1.3.6.1.4.1.12009.10.1.15
	O0300B	1	Not eligible - medical contraindication		Typical pattern	CD		55023-6	LA11091-8	1.3.6.1.4.1.12009.10.1.15
	O0300B	2	Offered and declined		Typical pattern	CD		55023-6	LA186-9	1.3.6.1.4.1.12009.10.1.15
	O0300B	3	Not offered		Typical pattern	CD		55023-6	LA187-7	1.3.6.1.4.1.12009.10.1.15
	O0400A1		Speech-language/audiology: individ minutes		Other response data type pattern	PQ	min	58218-9
	O0400A2		Speech-language/audiology: concur minutes		Other response data type pattern	PQ	min	58133-0
	O0400A3		Speech-language/audiology: group minutes		Other response data type pattern	PQ	min	58134-8
	O0400A4		Speech-language/audiology: number of days		Other response data type pattern	PQ	d	45760-6
	O0400A5		Speech-language/audiology: start date		Other response data type pattern	TS		55025-1
	O0400A6		Speech-language/audiology: end date		Other response data type pattern	TS		55026-9
	O0400B1		Occupational therapy: individ minutes		Other response data type pattern	PQ	min	58219-7
	O0400B2		Occupational therapy: concur minutes		Other response data type pattern	PQ	min	58136-3
	O0400B3		Occupational therapy: group minutes		Other response data type pattern	PQ	min	58137-1
	O0400B4		Occupational therapy: number of days		Other response data type pattern	PQ	d	45762-2
	O0400B5		Occupational therapy: start date		Other response data type pattern	TS		55027-7
	O0400B6		Occupational therapy: end date		Other response data type pattern	TS		55028-5
	O0400C1		Physical therapy: individ minutes		Other response data type pattern	PQ	min	58220-5
	O0400C2		Physical therapy: concur minutes		Other response data type pattern	PQ	min	58139-7
	O0400C3		Physical therapy: group minutes		Other response data type pattern	PQ	min	58140-5
	O0400C4		Physical therapy: number of days		Other response data type pattern	PQ	d	45764-8
	O0400C5		Physical therapy: start date		Other response data type pattern	TS		55029-3
	O0400C6		Physical therapy: end date		Other response data type pattern	TS		55030-1
	O0400D1		Respiratory therapy: number of minutes		Other response data type pattern	PQ	min	45767-1
	O0400D2		Respiratory therapy: number of days		Other response data type pattern	PQ	d	45766-3
	O0400E1		Psychological therapy: number of minutes		Other response data type pattern	PQ	min	45852-1
	O0400E2		Psychological therapy: number of days		Other response data type pattern	PQ	d	45768-9
	O0400F1		Recreational therapy: number of minutes		Other response data type pattern	PQ	min	55035-0
	O0400F2		Recreational therapy: number of days		Other response data type pattern	PQ	d	55036-8
	O0450A		Has therapy resumed	NEW RUGs ITEMS
	O0450B		Therapy resumption date	NEW RUGs ITEMS
	O0500A		Range of motion (passive): number of days		Other response data type pattern	PQ	d	45859-6
	O0500B		Range of motion (active): number of days		Other response data type pattern	PQ	d	45860-4
	O0500C		Splint or brace assistance: number of days		Other response data type pattern	PQ	d	45861-2
	O0500D		Bed mobility training: number of days		Other response data type pattern	PQ	d	45862-0
	O0500E		Transfer training: number of days		Other response data type pattern	PQ	d	45863-8
	O0500F		Walking training: number of days		Other response data type pattern	PQ	d	45864-6
	O0500G		Dressing and/or grooming training: number of days		Other response data type pattern	PQ	d	45865-3
	O0500H		Eating and/or swallowing training: number of days		Other response data type pattern	PQ	d	45866-1
	O0500I		Amputation/prosthesis training: number of days		Other response data type pattern	PQ	d	45867-9
	O0500J		Communication training: number of days		Other response data type pattern	PQ	d	45868-7
	O0600		Physician examinations: number of days		Other response data type pattern	PQ	d	55040-0
	O0700		Physician orders: number of days		Other response data type pattern	PQ	d	55041-8

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
P			Restraints
	P0100A		Restraints used in bed: bed rail		Typical pattern	CD		55044-2		1.3.6.1.4.1.12009.10.1.63
	P0100A	0	Not used		Typical pattern	CD		55044-2	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100A	1	Used less than daily		Typical pattern	CD		55044-2	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100A	2	Used daily		Typical pattern	CD		55044-2	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100B		Restraints used in bed: trunk restraint		Typical pattern	CD		55045-9		1.3.6.1.4.1.12009.10.1.63
	P0100B	0	Not used		Typical pattern	CD		55045-9	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100B	1	Used less than daily		Typical pattern	CD		55045-9	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100B	2	Used daily		Typical pattern	CD		55045-9	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100C		Restraints used in bed: limb restraint		Typical pattern	CD		55046-7		1.3.6.1.4.1.12009.10.1.63
	P0100C	0	Not used		Typical pattern	CD		55046-7	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100C	1	Used less than daily		Typical pattern	CD		55046-7	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100C	2	Used daily		Typical pattern	CD		55046-7	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100D		Restraints used in bed: other		Typical pattern	CD		55047-5		1.3.6.1.4.1.12009.10.1.63
	P0100D	0	Not used		Typical pattern	CD		55047-5	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100D	1	Used less than daily		Typical pattern	CD		55047-5	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100D	2	Used daily		Typical pattern	CD		55047-5	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100E		Restraints in chair/out of bed: trunk restraint		Typical pattern	CD		55048-3		1.3.6.1.4.1.12009.10.1.63
	P0100E	0	Not used		Typical pattern	CD		55048-3	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100E	1	Used less than daily		Typical pattern	CD		55048-3	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100E	2	Used daily		Typical pattern	CD		55048-3	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100F		Restraints in chair/out of bed: limb restraint		Typical pattern	CD		55049-1		1.3.6.1.4.1.12009.10.1.63
	P0100F	0	Not used		Typical pattern	CD		55049-1	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100F	1	Used less than daily		Typical pattern	CD		55049-1	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100F	2	Used daily		Typical pattern	CD		55049-1	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100G		Restraints in chair/out of bed: chair stops rising		Typical pattern	CD		55050-9		1.3.6.1.4.1.12009.10.1.63
	P0100G	0	Not used		Typical pattern	CD		55050-9	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100G	1	Used less than daily		Typical pattern	CD		55050-9	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100G	2	Used daily		Typical pattern	CD		55050-9	LA159-6	1.3.6.1.4.1.12009.10.1.63
	P0100H		Restraints in chair/out of bed: other		Typical pattern	CD		55051-7		1.3.6.1.4.1.12009.10.1.63
	P0100H	0	Not used		Typical pattern	CD		55051-7	LA157-0	1.3.6.1.4.1.12009.10.1.63
	P0100H	1	Used less than daily		Typical pattern	CD		55051-7	LA158-8	1.3.6.1.4.1.12009.10.1.63
	P0100H	2	Used daily		Typical pattern	CD		55051-7	LA159-6	1.3.6.1.4.1.12009.10.1.63

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
Q			Participation in Assessment and Goal Setting
	Q0100A		Resident participated in assessment		Typical pattern	CD		55054-1		1.3.6.1.4.1.12009.10.1.62
	Q0100A	0	No		Typical pattern	CD		55054-1	LA32-8	1.3.6.1.4.1.12009.10.1.62
	Q0100A	1	Yes		Typical pattern	CD		55054-1	LA33-6	1.3.6.1.4.1.12009.10.1.62
	Q0100B		Family/signif other participated in assessment		Typical pattern	CD		55074-9		1.3.6.1.4.1.12009.10.1.14
	Q0100B	0	No		Typical pattern	CD		55074-9	LA32-8	1.3.6.1.4.1.12009.10.1.14
	Q0100B	1	Yes		Typical pattern	CD		55074-9	LA33-6	1.3.6.1.4.1.12009.10.1.14
	Q0100B	9	No family or significant other		Typical pattern	CD		55074-9	LA11104-9	1.3.6.1.4.1.12009.10.1.14
	Q0100C		Guardian/legal rep participated in assessment		Typical pattern	CD		58221-3		1.3.6.1.4.1.12009.10.1.135
	Q0100C	0	No		Typical pattern	CD		58221-3	LA32-8	1.3.6.1.4.1.12009.10.1.135
	Q0100C	1	Yes		Typical pattern	CD		58221-3	LA33-6	1.3.6.1.4.1.12009.10.1.135
	Q0100C	9	No guardian or legally authorized representative		Typical pattern	CD		58221-3	LA12662-5	1.3.6.1.4.1.12009.10.1.135
	Q0300A		Resident's overall goal		Typical pattern	CD		55057-4		1.3.6.1.4.1.12009.10.1.12
	Q0300A	1	Expects to be discharged to the community		Typical pattern	CD		55057-4	LA11108-0	1.3.6.1.4.1.12009.10.1.12
	Q0300A	2	Expects to remain in this facility		Typical pattern	CD		55057-4	LA11109-8	1.3.6.1.4.1.12009.10.1.12
	Q0300A	3	Expects to be discharged to another facility/institution		Typical pattern	CD		55057-4	LA11110-6	1.3.6.1.4.1.12009.10.1.12
	Q0300A	9	Unknown or uncertain		Typical pattern	CD		55057-4	LA11107-2	1.3.6.1.4.1.12009.10.1.12
	Q0300B		Information source for resident's goal		Typical pattern	CD		55058-2		1.3.6.1.4.1.12009.10.1.73
	Q0300B	1	Resident		Typical pattern	CD		55058-2	LA11019-9	1.3.6.1.4.1.12009.10.1.73
	Q0300B	2	If not resident, then family or significant other		Typical pattern	CD		55058-2	LA11116-3	1.3.6.1.4.1.12009.10.1.73
	Q0300B	3	If not resident, family or significant other, then guardian or legally authorized representative		Typical pattern	CD		55058-2	LA12652-6	1.3.6.1.4.1.12009.10.1.73
	Q0300B	9	None of the above		Typical pattern	CD		55058-2	Q0300B-9	1.3.6.1.4.1.12009.10.1.11
	Q0400A		Active discharge plan for return to community		Typical pattern	CD		58146-2		1.3.6.1.4.1.12009.10.1.62
	Q0400A	0	No		Typical pattern	CD		58146-2	LA32-8	1.3.6.1.4.1.12009.10.1.62
	Q0400A	1	Yes		Typical pattern	CD		58146-2	LA33-6	1.3.6.1.4.1.12009.10.1.62
	Q0400B		Determination regarding discharge to community		Typical pattern	CD		58147-0		1.3.6.1.4.1.12009.10.1.74
	Q0400B	0	Determination not made		Typical pattern	CD		58147-0	LA12653-4	1.3.6.1.4.1.12009.10.1.74
	Q0400B	1	Discharge to community determined to be feasible		Typical pattern	CD		58147-0	LA12654-2	1.3.6.1.4.1.12009.10.1.74
	Q0400B	2	Discharge to community determined to be not feasible		Typical pattern	CD		58147-0	LA12655-9	1.3.6.1.4.1.12009.10.1.74
	Q0500A		Resident been asked about return to community		Typical pattern	CD		58148-8		1.3.6.1.4.1.12009.10.1.75
	Q0500A	0	No		Typical pattern	CD		58148-8	LA32-8	1.3.6.1.4.1.12009.10.1.75
	Q0500A	1	Yes--previous response was "no"		Typical pattern	CD		58148-8	LA12656-7	1.3.6.1.4.1.12009.10.1.75
	Q0500A	2	Yes--previous response was "yes"		Typical pattern	CD		58148-8	LA12657-5	1.3.6.1.4.1.12009.10.1.75
	Q0500A	3	Yes--previous response was "unknown"		Typical pattern	CD		58148-8	LA12658-3	1.3.6.1.4.1.12009.10.1.75
	Q0500B		Do you want to talk about returning to community		Typical pattern	CD		58149-6		1.3.6.1.4.1.12009.10.1.13
	Q0500B	0	No		Typical pattern	CD		58149-6	LA32-8	1.3.6.1.4.1.12009.10.1.13
	Q0500B	1	Yes		Typical pattern	CD		58149-6	LA33-6	1.3.6.1.4.1.12009.10.1.13
	Q0500B	9	Unknown or uncertain		Typical pattern	CD		58149-6	LA11107-2	1.3.6.1.4.1.12009.10.1.13
	Q0600		Referral been made to local contact agency		Typical pattern	CD		58150-4		1.3.6.1.4.1.12009.10.1.77
	Q0600	0	No--determination has been made by the resident and the care planning team that contact is not required		Typical pattern	CD		58150-4	LA12659-1	1.3.6.1.4.1.12009.10.1.77
	Q0600	1	No--referral not made		Typical pattern	CD		58150-4	LA12660-9	1.3.6.1.4.1.12009.10.1.77
	Q0600	2	Yes		Typical pattern	CD		58150-4	LA33-6	1.3.6.1.4.1.12009.10.1.77

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
T			Therapy Supplement for Medicare PPS

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
V
	V0100A		Prior OBRA reason for assessment		Typical pattern	CD		54583-0		1.3.6.1.4.1.12009.10.1.60
	V0100A	1	Admission assessment (required by day 14)		Typical pattern	CD		54583-0	LA10-4	1.3.6.1.4.1.12009.10.1.60
	V0100A	2	Quarterly review assessment		Typical pattern	CD		54583-0	LA15-3	1.3.6.1.4.1.12009.10.1.60
	V0100A	3	Annual assessment		Typical pattern	CD		54583-0	LA12-0	1.3.6.1.4.1.12009.10.1.60
	V0100A	4	Significant change in status assessment		Typical pattern	CD		54583-0	LA13-8	1.3.6.1.4.1.12009.10.1.60
	V0100A	5	Significant correction to prior comprehensive assessment		Typical pattern	CD		54583-0	LA10888-8	1.3.6.1.4.1.12009.10.1.60
	V0100A	6	Significant correction to prior quarterly assessment		Typical pattern	CD		54583-0	LA10889-6	1.3.6.1.4.1.12009.10.1.60
	V0100A	99	Not OBRA required assessment/tracking		Typical pattern	CD		54583-0	LA10893-8	1.3.6.1.4.1.12009.10.1.60
	V0100B		Prior PPS reason for assessment		Typical pattern	CD		54584-8		1.3.6.1.4.1.12009.10.1.59
	V0100B	1	5-day scheduled assessment		Typical pattern	CD		54584-8	LA10894-6	1.3.6.1.4.1.12009.10.1.59
	V0100B	2	14-day scheduled assessment		Typical pattern	CD		54584-8	LA10895-3	1.3.6.1.4.1.12009.10.1.59
	V0100B	3	30-day scheduled assessment		Typical pattern	CD		54584-8	LA10896-1	1.3.6.1.4.1.12009.10.1.59
	V0100B	4	60-day scheduled assessment		Typical pattern	CD		54584-8	LA10897-9	1.3.6.1.4.1.12009.10.1.59
	V0100B	5	90-day scheduled assessment		Typical pattern	CD		54584-8	LA10898-7	1.3.6.1.4.1.12009.10.1.59
	V0100B	6	Readmission/return assessment		Typical pattern	CD		54584-8	LA10899-5	1.3.6.1.4.1.12009.10.1.59
	V0100B	7	Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)		Typical pattern	CD		54584-8	LA10900-1	1.3.6.1.4.1.12009.10.1.59
	V0100B	99	Not PPS assessment		Typical pattern	CD		54584-8	LA10903-5	1.3.6.1.4.1.12009.10.1.59
	V0100C		Prior assessment reference date		Other response data type pattern	TS		58151-2
	V0100D		Prior assessment BIMS summary score		Other response data type pattern	INT		58152-0
	V0100E		Prior asmt PHQ res: total mood severity score		Other response data type pattern	INT		58153-8
	V0100F		Prior asmt PHQ staff: total mood score		Other response data type pattern	INT		58153-8
	V0200A01A		CAA-Delirium: triggered		Multiple response pattern	BL		58157-9
	V0200A01B		CAA-Delirium: plan		Multiple response pattern	BL		58158-7
	V0200A02A		CAA-Cognitive loss/dementia: triggered		Multiple response pattern	BL		58159-5
	V0200A02B		CAA-Cognitive loss/dementia: plan		Multiple response pattern	BL		58160-3
	V0200A03A		CAA-Visual function: triggered		Multiple response pattern	BL		58226-2
	V0200A03B		CAA-Visual function: plan		Multiple response pattern	BL		58225-4
	V0200A04A		CAA-Communication: triggered		Multiple response pattern	BL		58161-1
	V0200A04B		CAA-Communication: plan		Multiple response pattern	BL		58162-9
	V0200A05A		CAA-ADL functional/rehab potential: triggered		Multiple response pattern	BL		58163-7
	V0200A05B		CAA-ADL functional/rehab potential: plan		Multiple response pattern	BL		58164-5
	V0200A06A		CAA-Urinary incont/indwell catheter: triggered		Multiple response pattern	BL		58165-2
	V0200A06B		CAA-Urinary incont/indwell catheter: plan		Multiple response pattern	BL		58166-0
	V0200A07A		CAA-Psychosocial well-being: triggered		Multiple response pattern	BL		58167-8
	V0200A07B		CAA-Psychosocial well-being: plan		Multiple response pattern	BL		58168-6
	V0200A08A		CAA-Mood state: triggered		Multiple response pattern	BL		58169-4
	V0200A08B		CAA-Mood state: plan		Multiple response pattern	BL		58170-2
	V0200A09A		CAA-Behavioral symptoms: triggered		Multiple response pattern	BL		58171-0
	V0200A09B		CAA-Behavioral symptoms: plan		Multiple response pattern	BL		58172-8
	V0200A10A		CAA-Activities: triggered		Multiple response pattern	BL		58173-6
	V0200A10B		CAA-Activities: plan		Multiple response pattern	BL		58174-4
	V0200A11A		CAA-Falls: triggered		Multiple response pattern	BL		58175-1
	V0200A11B		CAA-Falls: plan		Multiple response pattern	BL		58176-9
	V0200A12A		CAA-Nutritional status: triggered		Multiple response pattern	BL		58177-7
	V0200A12B		CAA-Nutritional status: plan		Multiple response pattern	BL		58178-5
	V0200A13A		CAA-Feeding tubes: triggered		Multiple response pattern	BL		8179-3
	V0200A13B		CAA-Feeding tubes: plan		Multiple response pattern	BL		58180-1
	V0200A14A		CAA-Dehydration/fluid maintenance: triggered		Multiple response pattern	BL		58181-9
	V0200A14B		CAA-Dehydration/fluid maintenance: plan		Multiple response pattern	BL		58182-7
	V0200A15A		CAA-Dental care: triggered		Multiple response pattern	BL		58183-5
	V0200A15B		CAA-Dental care: plan		Multiple response pattern	BL		58184-3
	V0200A16A		CAA-Pressure ulcer: triggered		Multiple response pattern	BL		58185-0
	V0200A16B		CAA-Pressure ulcer: plan		Multiple response pattern	BL		58186-8
	V0200A17A		CAA-Psychotropic drug use: triggered		Multiple response pattern	BL		58187-6
	V0200A17B		CAA-Psychotropic drug use: plan		Multiple response pattern	BL		58188-4
	V0200A18A		CAA-Physical restraints: triggered		Multiple response pattern	BL		58189-2
	V0200A18B		CAA-Physical restraints: plan		Multiple response pattern	BL		58190-0
	V0200A19A		CAA-Pain: triggered		Multiple response pattern	BL		58191-8
	V0200A19B		CAA-Pain: plan		Multiple response pattern	BL		58192-6
	V0200A20A		CAA-Return to community referral: triggered		Multiple response pattern	BL		58193-4
	V0200A20B		CAA-Return to community referral: plan		Multiple response pattern	BL		58194-2
	V0200B2		CAA-Assessment process signature date		Other response data type pattern	TS
	V0200C2		CAA-Care planning signature date		Other response data type pattern	TS

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
X
	X0100		Correction: type of transaction		Typical pattern	CD		58198-3		1.3.6.1.4.1.12009.10.1.159
	X0100	1	Add new record		Typical pattern	CD		58198-3	LA12663-3	1.3.6.1.4.1.12009.10.1.159
	X0100	2	Modify existing record		Typical pattern	CD		58198-3	LA12664-1	1.3.6.1.4.1.12009.10.1.159
	X0100	3	Inactivate existing record		Typical pattern	CD		58198-3	LA12665-8	1.3.6.1.4.1.12009.10.1.159
	X0150		Correction: type of provider		Typical pattern	CD		54582-2		1.3.6.1.4.1.12009.10.1.61
	X0150	1	Nursing home (SNF/NF)		Typical pattern	CD		54582-2	LA10882-1	1.3.6.1.4.1.12009.10.1.61
	X0150	2	Swing bed		Typical pattern	CD		54582-2	LA10883-9	1.3.6.1.4.1.12009.10.1.61
	X0200A		Correction: resident first name		Other Response Data Type Pattern	ED		54503-8
	X0200C		Correction: resident last name		Other Response Data Type Pattern	ED		54503-8
	X0300		Correction: resident gender		Typical pattern	CD		46098-0		2.16.840.1.113883.5.1
	X0300	1	Male		Typical pattern	CD		46098-0	LA2-8
	X0300	2	Female		Typical pattern	CD		46098-0	LA3-6
	X0400		Correction: resident birth date		Other response data type pattern	TS		21112-8
	X0500		Correction: resident social security number		Other Response Data Type Pattern	ED		45966-9
	X0600A		Correction: OBRA reason for assessment		Typical pattern	CD		54583-0		1.3.6.1.4.1.12009.10.1.60
	X0600A	1	Admission assessment (required by day 14)		Typical pattern	CD		54583-0	LA10-4	1.3.6.1.4.1.12009.10.1.60
	X0600A	2	Quarterly review assessment		Typical pattern	CD		54583-0	LA15-3	1.3.6.1.4.1.12009.10.1.60
	X0600A	3	Annual assessment		Typical pattern	CD		54583-0	LA12-0	1.3.6.1.4.1.12009.10.1.60
	X0600A	4	Significant change in status assessment		Typical pattern	CD		54583-0	LA13-8	1.3.6.1.4.1.12009.10.1.60
	X0600A	5	Significant correction to prior comprehensive assessment		Typical pattern	CD		54583-0	LA10888-8	1.3.6.1.4.1.12009.10.1.60
	X0600A	6	Significant correction to prior quarterly assessment		Typical pattern	CD		54583-0	LA10889-6	1.3.6.1.4.1.12009.10.1.60
	X0600A	99	Not OBRA required assessment/ tracking		Typical pattern	CD		54583-0	LA10893-8	1.3.6.1.4.1.12009.10.1.60
	X0600B		Correction: PPS reason for assessment		Typical pattern	CD		54584-8		1.3.6.1.4.1.12009.10.1.59
	X0600B	1	5-day scheduled assessment		Typical pattern	CD		54584-8	LA10894-6	1.3.6.1.4.1.12009.10.1.59
	X0600B	2	14-day scheduled assessment		Typical pattern	CD		54584-8	LA10895-3	1.3.6.1.4.1.12009.10.1.59
	X0600B	3	30-day scheduled assessment		Typical pattern	CD		54584-8	LA10896-1	1.3.6.1.4.1.12009.10.1.59
	X0600B	4	60-day scheduled assessment		Typical pattern	CD		54584-8	LA10897-9	1.3.6.1.4.1.12009.10.1.59
	X0600B	5	90-day scheduled assessment		Typical pattern	CD		54584-8	LA10898-7	1.3.6.1.4.1.12009.10.1.59
	X0600B	6	Readmission/return assessment		Typical pattern	CD		54584-8	LA10899-5	1.3.6.1.4.1.12009.10.1.59
	X0600B	7	Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)		Typical pattern	CD		54584-8	LA10900-1	1.3.6.1.4.1.12009.10.1.59
	X0600B	99	Not PPS assessment		Typical pattern	CD		54584-8	LA10903-5	1.3.6.1.4.1.12009.10.1.59
	X0600C		Correction: OMRA assessment		Typical pattern	CD		54585-5		1.3.6.1.4.1.12009.10.1.65
	X0600C	0	No		Typical pattern	CD		54585-5	LA32-8	1.3.6.1.4.1.12009.10.1.65
	X0600C	1	Start of therapy assessment		Typical pattern	CD		54585-5	LA12624-5	1.3.6.1.4.1.12009.10.1.65
	X0600C	2	End of therapy assessment		Typical pattern	CD		54585-5	LA12625-2	1.3.6.1.4.1.12009.10.1.65
	X0600C	3	Both Start and End of therapy assessment		Typical pattern	CD		54585-5	LA12626-0	1.3.6.1.4.1.12009.10.1.65
	X0600D		Correction: Swing bed clinical change asmt		Typical pattern	CD		58107-4		1.3.6.1.4.1.12009.10.1.62
	X0600D	0	No		Typical pattern	CD		58107-4	LA32-8	1.3.6.1.4.1.12009.10.1.62
	X0600D	1	Yes		Typical pattern	CD		58107-4	LA33-6	1.3.6.1.4.1.12009.10.1.62
	X0600F		Correction: entry/discharge reporting		Typical pattern	CD		58108-2		1.3.6.1.4.1.12009.10.1.66
	X0600F	1	Entry record		Typical pattern	CD		58108-2	LA12627-8	1.3.6.1.4.1.12009.10.1.66
	X0600F	10	Discharge assessment - return not anticipated		Typical pattern	CD		58108-2	LA12628-6	1.3.6.1.4.1.12009.10.1.66
	X0600F	11	Discharge assessment - return anticipated		Typical pattern	CD		58108-2	LA12629-4	1.3.6.1.4.1.12009.10.1.66
	X0600F	12	Death in facility record		Typical pattern	CD		58108-2	LA12630-2	1.3.6.1.4.1.12009.10.1.66
	X0600F	99	Not entry/discharge		Typical pattern	CD		58108-2	LA12631-0	1.3.6.1.4.1.12009.10.1.66
	X0700A		Correction: assessment reference date		Other response data type pattern	TS		54593-9
	X0700B		Correction: discharge date		Other response data type pattern	TS		52525-3
	X0700C		Correction: entry date		Other response data type pattern	TS		50786-3
	X0800		Correction: correction number		Other response data type pattern	INT		58200-7
	X0900A		Correction: modif reasons - transcription error		Multiple response pattern	BL		58201-5
	X0900B		Correction: modif reasons - data entry error		Multiple response pattern	BL		58202-3
	X0900C		Correction: modif reasons - software error		Multiple response pattern	BL		58203-1
	X0900D		Correction: modif reasons - item coding error		Multiple response pattern	BL		58227-0
	X0900Z		Correction: modif reasons - other error		Multiple response pattern	BL		58204-9
	X1050A		Correction: inact reasons - event did not occur		Multiple response pattern	BL		58207-2
	X1050Z		Correction: inact reasons - other reason		Multiple response pattern	BL		58208-0
	X1100A		Correction: attestor first name		Other response data type pattern	ED
	X1100B		Correction: attestor last name		Other response data type pattern	ED
	X1100E		Correction: attestation date		Other response data type pattern	TS

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
Z			Assessment Administration
	Z0100A		Medicare Part A: HIPPS code		Other response data type pattern	ED		55065-7
	Z0100B		Medicare Part A: RUG version code		Other response data type pattern	ED		55066-5
	Z0100C		Medicare Part A: Medicare short stay asmt		Typical pattern	CD		58421-9		1.3.6.1.4.1.12009.10.1.62
	Z0100C	0	No		Typical pattern	CD		58421-9	LA32-8	1.3.6.1.4.1.12009.10.1.62
	Z0100C	1	Yes		Typical pattern	CD		58421-9	LA33-6	1.3.6.1.4.1.12009.10.1.62
	Z0150A		Medicare Part A: non-therapy HIPPS code		Other response data type pattern	ED		58210-6
	Z0150B		Medicare Part A: non-therapy RUG version code		Other response data type pattern	ED		58211-4
	Z0200A		State case mix: RUG group		Other response data type pattern	ED		55068-1
	Z0200B		State case mix: RUG version code		Other response data type pattern	ED		55069-9
	Z0250A		State case mix: Alternate RUG group		Other response data type pattern	ED		58212-2
	Z0250B		State case mix: Alternate RUG version code		Other response data type pattern	ED		58213-0
	Z0500B		Date RN signed assessment as complete	See CDA X-Path Mapping Table 27 Implementation Guide for CDA R2 - CDA Framework/ MDS Questionnaire Assessment DSTU, Update Release 2.0 (April 21, 2010)

Section	CMS Question ID	Answer	CMS Description Light Blue Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Pattern	Data Type	Units	LOINC Question Code	LOINC Answer Code	LOINC Answer Set OID
OTHER
	FAC_ID		Assigned facility/provider submission ID		Other response data type pattern	ED		55077-2
	SFTWR_PROD_ NAME		Software product name
	SFTWR_PROD_ NAME		Software product name
	SFTWR_PROD_ VRSN_CD		Software product version code
	SFTWR_PROD_ VRSN_CD		Software product version code
	SFTWR_VNDR_ EMAIL_ADR		Software vendor email address
	SFTWR_VNDR_ EMAIL_ADR		Software vendor email address
	SFTWR_VNDR_ID		Software vendor federal employer tax ID
	SFTWR_VNDR_ID		Software vendor federal employer tax ID
	SFTWR_VNDR_ NAME		Software vendor company name
	SFTWR_VNDR_ NAME		Software vendor company name
	SPEC_VRSN_CD		Specifications version code
	SPEC_VRSN_CD		Specifications version code
	ITM_SBST_CD		Item subset code
	ITM_SBST_CD	NCN	Nursing home comprehensive assessment
	ITM_SBST_CD	NCP	Nursing home comprehensive assessment coupled with PPS assessment
	ITM_SBST_CD	NDE	Nursing home discharge coupled with EMCA
	ITM_SBST_CD	NDN	Nursing home discharge
	ITM_SBST_CD	NEN	Nursing home entry
	ITM_SBST_CD	NNE	Nursing home EMCA
	ITM_SBST_CD	NNN	Nursing home not OMBRA and not PPS assessment
	ITM_SBST_CD	NNP	Nursing home PPS assessment
	ITM_SBST_CD	NQN	Nursing home quarterly assessment
	ITM_SBST_CD	NQP	Nursing home quarterly assessment coupled with PPS assessment
	ITM_SBST_CD	SDE	Swing bed discharge coupled with EMCA
	ITM_SBST_CD	SDN	Swing bed discharge
	ITM_SBST_CD	SEN	Swing bed entry
	ITM_SBST_CD	SNE	Swing bed EMCA
	ITM_SBST_CD	SNN	Swing bed not a PPS assessment
	ITM_SBST_CD	SNP	Swing bed PPS assessment
	ITM_SBST_CD	SNS	Swing bed clinical change assessment
	ITM_SBST_CD	XXX	Inactivation transaction
	PRODN_TEST_CD		Production/test indicator
	PRODN_TEST_CD	P	Product submission
	PRODN_TEST_CD	T	Test submission

MDS3.0 Items Mapping -- Model Of Meaning

Section	CMS Question ID	Answer	CMS Description Light Orange Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Mapping Based on the Following Pattern for Representation of Data Element	SNOMED CT Code	SNOMED CT Fully Specified Name	ICD-9-CM Code - Section 1 Only	ICD-10-CM Code - Section 1 Only	CDC Race & Ethnicity Codes*	Codes for Vaccines Administered (CVX) - Section O Only
A			Identification Information
	A0100A		Facility National Provider Identifier (NPI)			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0100B		Facility CMS Certification Number (CCN)			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0100C		State provider number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0200		Type of provider			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0200	1	Nursing home (SNF/NF)
	A0200	2	Swing bed
	A0310A		Type of assessment: OBRA			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310A	1	Admission assessment (required by day 14)
	A0310A	2	Quarterly review assessment
	A0310A	3	Annual assessment
	A0310A	4	Significant change in status assessment
	A0310A	5	Significant correction to prior comprehensive assessment
	A0310A	6	Significant correction to prior quarterly assessment
	A0310A	99	Not OBRA required assessment/ tracking
	A0310B		Type of assessment: PPS			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310B	1	5-day scheduled assessment
	A0310B	2	14-day scheduled assessment
	A0310B	3	30-day scheduled assessment
	A0310B	4	60-day scheduled assessment
	A0310B	5	90-day scheduled assessment
	A0310B	6	Readmission/return assessment
	A0310B	7	Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)
	A0310B	99	Not a PPS assessment
	A0310C		Type of assessment: OMRA			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310C	0	No
	A0310C	1	Start of therapy assessment
	A0310C	2	End of therapy assessment
	A0310C	3	Both Start and End of therapy assessment
	A0310D		Swing bed clinical change assessment			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310D	0	No
	A0310D	1	Yes
	A0310E		First assessment since most recent entry			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310E	0	No
	A0310E	1	Yes
	A0310F		Entry/discharge reporting			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0310F	1	Entry record
	A0310F	10	Discharge assessment - return not anticipated
	A0310F	11	Discharge assessment - return anticipated
	A0310F	12	Death in facility record
	A0310F	99	Not entry/discharge record
	A0410		Submission requirement			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0410	1	Neither federal nor state required submission
	A0410	2	State but not federal required submission (FOR NURSING HOMES ONLY)
	A0410	3	Federal required submission
	A0500A		Resident first name			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0500B		Resident middle initial			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0500C		Resident last name			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0500D		Resident name suffix			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0600A		Social Security Number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0600B		Resident Medicare/ railroad insurance number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0700		Resident Medicaid number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0800		Gender			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A0800	1	Male
	A0800	2	Female
	A0900		Birthdate			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1000A		Ethnicity: American Indian or Alaska Native	*ONC Final Rule (7/28/2010) requires use of the Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directive No. 15, October 30, 1997. This is not a vocabulary. *HITSP Component C-32 (HITSP Summary Documents Using HL7 Continuity of Care Document (CCD)) requires use of the CDC Race and Ethnicity vocabulary for reporting race and ethnicity (see Column Q). *See DSTU for detailis on representation of Race/ Ethnicity data.	ETHNICITY PATTERN					1002-5
	A1000B		Ethnicity: Asian		ETHNICITY PATTERN					2028-9
	A1000C		Ethnicity: Black or African American		ETHNICITY PATTERN					2054-5
	A1000D		Ethnicity: Hispanic or Latino		ETHNICITY PATTERN					2135-2
	A1000E		Ethnicity: Native Hawaiian/Pacific Islander		ETHNICITY PATTERN					2076-8
	A1000F		Ethnicity: White		ETHNICITY PATTERN					2106-3
	A1100A		Does the resident need or want an interpreter		ASSERTION PATTERN
	A1100A	0	No		Assertion pattern	315595002	interpreter not needed (finding)
	A1100A	1	Yes		Assertion pattern	315594003	interpreter needed (finding)
	A1100A	9	Unable to determine			Concept Not Mapped (Reason #5) -- Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT
	A1100B		Preferred language			Concept Not Mapped (Reason #6) -- Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping
	A1200		Marital status			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1200	1	Never married
	A1200	2	Married
	A1200	3	Widowed
	A1200	4	Separated
	A1200	5	Divorced
	A1300A	MDCL_REC_ NUM	Medical record number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1300B	ROOM_NUM	Room number			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1300C	PREFRD_NAME	Name by which resident prefers to be addressed			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1300D		Lifetime occupation(s)			Concept Not Mapped (Reason #6) -- Question responses are free text format and do not provide a fixed concept for SNOMED CT mapping
	A1500		Resident evaluated by PASRR			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1500	0	No
	A1500	1	Yes
	A1500	9	Not a Medicaid certified unit
	A1550A		MR/DD status: Down syndrome		Assertion pattern	41040004	complete trisomy 21 syndrome (disorder)
	A1550B		MR/DD status: Autism		Assertion pattern	408856003	autistic disorder (disorder)
	A1550C		MR/DD status: Epilepsy		Assertion pattern	84757009	epilepsy (disorder)
	A1550D		MR/DD status: other organic MR/DD condition			Concept Not Mapped (Reason #5) -- Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT
	A1550E		MR/DD status: MR/DD with no organic condition			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	A1550Z		MR/DD status: none of the above			Concept Not Mapped (Reason #5) -- Ambiguous concepts such as "none", "other", "unknown", etc., cannot be mapped to SNOMED CT
	A1600		Entry date (date of admission/reentry in facility)			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1700		Type of entry			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1700	1	Admission
	A1700	2	Reentry
	A1800		Entered from			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A1800	1	Community (private home/apt., board/ care, assisted living, group home)
	A1800	2	Another nursing home or swing bed
	A1800	3	Acute hospital
	A1800	4	Psychiatric hospital
	A1800	5	Inpatient rehabilitation facility
	A1800	6	MR/DD facility
	A1800	7	Hospice
	A1800	99	Other
	A2000		Discharge date			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2100		Discharge status			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2100	1	Community (private home/apt., board/ care, assisted living, group home)
	A2100	2	Another nursing home or swing bed
	A2100	3	Acute hospital
	A2100	4	Psychiatric hospital
	A2100	5	Inpatient rehabilitation facility
	A2100	6	MR/DD facility
	A2100	7	Hospice
	A2100	8	Deceased
	A2100	99	Other
	A2200		Previous asmt reference date for signif correction			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2300		Assessment reference date			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2400A		Has resident had Medicare-covered stay			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2400A	0	No
	A2400A	1	Yes
	A2400B		Start date of most recent Medicare stay			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians
	A2400C		End date of most recent Medicare stay			Concept Not Mapped (Reason #1) -- This demographic/ administrative data element is mapped to the CDA Header or is not relevant/useful to other providers/ clinicians

Section	CMS Question ID	Answer	CMS Description Light Orange Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Mapping Based on the Following Pattern for Representation of Data Element	SNOMED CT Code	SNOMED CT Fully Specified Name	ICD-9-CM Code - Section 1 Only	ICD-10-CM Code - Section 1 Only	CDC Race & Ethnicity Codes*	Codes for Vaccines Administered (CVX) - Section O Only
B			Hearing, Speech, and Vision
	B0100		Comatose		ASSERTION PATTERN
	B0100	0	No		Assertion pattern	271591004	fully conscious (finding)
	B0100	1	Yes		Assertion pattern	371632003	coma (disorder)
	B0200		Hearing		ASSERTION PATTERN
	B0200	0	Adequate - no difficulty in normal conversation, social interaction, listening to TV		Assertion pattern	162339002	hearing normal (finding)
	B0200	1	Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)		Assertion pattern	162340000	hearing difficulty (finding)
	B0200	2	Moderate difficulty - speaker has to increase volume and speak distinctly		Assertion pattern	425091001	difficulty hearing normal speech tones (finding)
	B0200	3	Highly impaired - absence of useful hearing		Assertion pattern	306972000	unable to hear loud voice (finding)
	B0300		Hearing aid		ASSERTION PATTERN
	B0300	0	No		Assertion pattern	285056001	does not use hearing aid (finding)
	B0300	1	Yes		Assertion pattern	285055002	does use hearing aid (finding)
	B0600		Speech clarity		ASSERTION PATTERN
	B0600	0	Clear speech - distinct intelligible words		Assertion pattern	286296002	does articulate clearly (finding)
	B0600	1	Unclear speech - slurred or mumbled words		Assertion pattern	286298001	does not articulate clearly (finding)
	B0600	2	No speech - absence of spoken words		Assertion pattern	286371003	does not speak (finding)
	B0700		Makes self understood		QUESTION/ ANSWER PATTERN	288743004	ability to make self understood (observable entity)
	B0700	0	Understood		Question/Answer pattern	288746007	does make self understood (finding)
	B0700	1	Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time		Question/Answer pattern	288748008	difficulty making self understood (finding)
	B0700	2	Sometimes understood - ability is limited to making concrete requests		Question/Answer pattern	288748008	difficulty making self understood (finding)
	B0700	3	Rarely/never understood		Question/Answer pattern	288747003	does not make self understood (finding)
	B0800		Ability to understand others		QUESTION/ ANSWER PATTERN	395659009	ability to comprehend (observable entity)
	B0800	0	Understands - clear comprehension			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	B0800	1	Usually understands - misses some part/ intent of message but comprehends most conversation		Question/Answer pattern	64270008	disturbance of understand-ing (finding)
	B0800	2	Sometimes understands - responds adequately to simple, direct communication only		Question/Answer pattern	64270008	disturbance of understand-ing (finding)
	B0800	3	Rarely/never understands		Question/Answer pattern	53314000	Akatamath-esia (finding)
	B1000		Vision		QUESTION/ ANSWER PATTERN	415823006	vision observable (observable entity)
	B1000	0	Adequate - sees fine detail, including regular print in newspapers/books		Question/Answer pattern	45089002	normal vision (finding)
	B1000	1	Impaired - sees large print, but not regular print in newspapers/books		Question/Answer pattern	424883003	difficulty seeing small print (finding)
	B1000	2	Moderately Impaired - limited vision; not able to see newspaper headlines but can identify objects		Question/Answer pattern	285163004	able to recognize objects by sight (finding)
	B1000	3	Highly impaired - object identification in question, but eyes appear to follow objects		Question/Answer pattern	170728008	poor visual acuity (finding)
	B1000	4	Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects		Question/Answer pattern	397541004	severe visual impairment (disorder)
	B1200		Corrective lenses		ASSERTION PATTERN
	B1200	0	No			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	B1200	1	Yes		Assertion pattern	365237006	finding related to ability to use appliances for sensory impairment (finding)

Section	CMS Question ID	Answer	CMS Description Light Orange Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Mapping Based on the Following Pattern for Representation of Data Element	SNOMED CT Code	SNOMED CT Fully Specified Name	ICD-9-CM Code - Section 1 Only	ICD-10-CM Code - Section 1 Only	CDC Race & Ethnicity Codes*	Codes for Vaccines Administered (CVX) - Section O Only
C			Cognitive Patterns
	C0100		BIMS: should resident interview be conducted		ASSERTION PATTERN
	C0100	0	No (resident is rarely/never understood)		Assertion pattern	288747003	does not make self understood (finding)
	C0100	1	Yes		Assertion pattern	288744005	able to make self understood (finding)
	C0200		BIMS res interview: repetition of three words			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0200	0	None			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0200	1	One			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0200	2	Two			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0200	3	Three			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0300A		BIMS res interview: able to report correct year		QUESTION/ ANSWER PATTERN	285195003	ability to remember current year (observable entity)
	C0300A	0	Missed by > 5 years or no answer		Question/Answer pattern	285197006	unable to remember current year (finding)
	C0300A	1	Missed by 2-5 years		Question/Answer pattern	285197006	unable to remember current year (finding)
	C0300A	2	Missed by 1 year		Question/Answer pattern	285197006	unable to remember current year (finding)
	C0300A	3	Correct		Question/Answer pattern	285196002	able to remember current year (finding)
	C0300B		BIMS res interview: able to report correct month		QUESTION/ ANSWER PATTERN	283895004	ability to remember month of year (observable entity)
	C0300B	0	Missed by > 1 month or no answer		Question/Answer pattern	285194004	unable to remember month of year (finding)
	C0300B	1	Missed by 6 days to 1 month		Question/Answer pattern	285194004	unable to remember month of year (finding)
	C0300B	2	Accurate within 5 days		Question/Answer pattern	285193005	able to remember month of year (finding)
	C0300C		BIMS res interview: can report correct day of week		QUESTION/ ANSWER PATTERN	283894000	ability to remember day of the week (observable entity)
	C0300C	0	Incorrect or no answer		Question/Answer pattern	285191007	unable to remember day of the week (finding)
	C0300C	1	Correct		Question/Answer pattern	28519008	unable to remember day of the week (finding)
	C0400A		BIMS res interview: able to recall “sock”		QUESTION/ ANSWER PATTERN	363891004	memory test observable (observable entity)
	C0400A	0	No - could not recall		Question/Answer pattern	285225003	unable to remember objects (finding)
	C0400A	1	Yes, after cueing (“something to wear”)		Question/Answer pattern	285224004	able to remember objects (finding)
	C0400A	2	Yes, no cue required		Question/Answer pattern	285224004	able to remember objects (finding)
	C0400B		BIMS res interview: able to recall “blue”		QUESTION/ ANSWER PATTERN	363891004	memory test observable (observable entity)
	C0400B	0	No - could not recall		Question/Answer pattern	285225003	unable to remember objects (finding)
	C0400B	1	Yes, after cueing (“a color”)		Question/Answer pattern	285224004	able to remember objects (finding)
	C0400B	2	Yes, no cue required		Question/Answer pattern	285224004	able to remember objects (finding)
	C0400C		BIMS res interview: able to recall “bed”		QUESTION/ ANSWER PATTERN	363891004	memory test observable (observable entity)
	C0400C	0	No - could not recall		Question/Answer pattern	285225003	unable to remember objects (finding)
	C0400C	1	Yes, after cueing (“a piece of furniture”)		Question/Answer pattern	285224004	able to remember objects (finding)
	C0400C	2	Yes, no cue required		Question/Answer pattern	285224004	able to remember objects (finding)
	C0500		BIMS res interview: summary score			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	C0600		Staff asmt mental status: conduct asmt		QUESTION/ ANSWER PATTERN	247571009	general mental state (observable entity)
	C0600	0	No (resident was able to  complete interview)		Question/Answer pattern	288732007	able to respond to communica-tion by others (finding)
	C0600	1	Yes (resident was unable to complete interview)		Question/Answer pattern	288733002	unable to respond to communica-tion by others (finding)
	C0700		Staff asmt mental status: short-term memory OK		ASSERTION PATTERN
	C0700	0	Memory OK		Assertion pattern	247590001	short-term memory within normal limits (finding)
	C0700	1	Memory problem		Assertion pattern	247592009	poor short-term memory (finding)
	C0800		Staff asmt mental status: long-term memory OK		ASSERTION PATTERN
	C0800	0	Memory OK		Assertion pattern	247587007	long-term memory within normal limits (finding)
	C0800	1	Memory problem		Assertion pattern	247588002	poor long-term memory (finding)
	C0900A		Staff asmt mental status: recall current season		Assertion pattern	165284008	memory: present time known (finding)
	C0900B		Staff asmt mental status: recall location of room		Assertion pattern	165287001	memory: present place known (finding)
	C0900C		Staff asmt mental status: recall staff names/faces		Assertion pattern	285227006	able to remember faces (finding)
	C0900D		Staff asmt mental status: recall in nursing home		Assertion pattern	165287001	memory: present place known (finding)
	C0900Z		Staff asmt mental status: none of above recalled		Assertion pattern	386807006	memory impairment (finding)
	C1000		Cognitive skills for daily decision making		QUESTION/ ANSWER PATTERN	413383002	ability to make decisions (observable entity)
	C1000	0	Independent - decisions consistent/ reasonable		Question/Answer pattern	304650003	able to use decision making strategies (finding)
	C1000	1	Modified independence - some difficulty in new situations only		Question/Answer pattern	304652006	difficulty using decision making strategies (finding)
	C1000	2	Moderately impaired - decisions poor; cues/ supervision required		Question/Answer pattern	304652006	difficulty using decision making strategies (finding)
	C1000	3	Severely impaired - never/rarely made decisions		Question/Answer pattern	304651004	unable to use decision making strategies (finding)
	C1300A		Signs of delirium: inattention		QUESTION/ ANSWER PATTERN	52963003	attentiveness (observable entity)
	C1300A	0	Behavior not present		Question/Answer pattern	288769005	able to direct attention (finding)
	C1300A	1	Behavior continuously present, does not fluctuate		Question/Answer pattern	288773008	difficulty directing attention (finding)
	C1300A	2	Behavior present, fluctuates (comes and goes, changes in severity)		Question/Answer pattern	247767009	integrated attention for short spells (finding)
	C1300B		Signs of delirium: disorganized thinking		QUESTION/ ANSWER PATTERN	88952004	thinking, function (observable entity)
	C1300B	0	Behavior not present		Question/Answer pattern	225662002	able to think clearly (finding)
	C1300B	1	Behavior continuously present, does not fluctuate		Question/Answer pattern	247640008	unable to think clearly (finding)
	C1300B	2	Behavior present, fluctuates (comes and goes, changes in severity)		Question/Answer pattern	88962006	incomplete clearminded-ness (finding)
	C1300C		Signs of delirium: altered level of consciousness		QUESTION/ ANSWER PATTERN	6942003	level of conscious-ness (observable entity)
	C1300C	0	Behavior not present		Question/Answer pattern	248222000	conscious-ness unimpaired (finding)
	C1300C	1	Behavior continuously present, does not fluctuate		Question/Answer pattern	3006004	disturbance of conscious-ness (finding)
	C1300C	2	Behavior present, fluctuates (comes and goes, changes in severity)		Question/Answer pattern	3006004	disturbance of conscious-ness (finding)
	C1300D		Signs of delirium: psychomotor retardation		QUESTION/ ANSWER PATTERN	48761009	motor behavior (observable entity)
	C1300D	0	Behavior not present		Question/Answer pattern	17621005	normal (qualifier value)
	C1300D	1	Behavior continuously present, does not fluctuate		Question/Answer pattern	398991009	motor retardation (finding)
	C1300D	2	Behavior present, fluctuates (comes and goes, changes in severity)		Question/Answer pattern	398991009	motor retardation (finding)
	C1600		Acute onset mental status change		ASSERTION PATTERN
	C1600	0	No		Assertion pattern	359748005	patient's condition the same (finding)
	C1600	1	Yes		Assertion pattern	419284004	altered mental status (finding)

Section	CMS Question ID	Answer	CMS Description Light Orange Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Mapping Based on the Following Pattern for Representation of Data Element	SNOMED CT Code	SNOMED CT Fully Specified Name	ICD-9-CM Code - Section 1 Only	ICD-10-CM Code - Section 1 Only	CDC Race & Ethnicity Codes*	Codes for Vaccines Administered (CVX) - Section O Only
D			Mood
	D0100		PHQ: should resident mood interview be conducted		ASSERTION PATTERN
	D0100	0	No (resident is rarely/never understood)		Assertion pattern	288745006	unable to make self understood (finding)
	D0100	1	Yes		Assertion pattern	288744005	able to make self understood (finding)
	D0200A1		PHQ res: little interest or pleasure - presence		ASSERTION PATTERN
	D0200A1	0	No (enter 0 in column 2)		Assertion pattern	134417007	level of mood - normal (finding)
	D0200A1	1	Yes (enter 0-3 in column 2)		Assertion pattern	247753000	loss of interest (finding)
	D0200A1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200A2		PHQ res: little interest or pleasure - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200A2	0	Never or 1 day
	D0200A2	1	2-6 Days (Several days)
	D0200A2	2	7-11 Days (Half or more of the days)
	D0200A2	3	12-14 Days (Nearly every day)
	D0200B1		PHQ res: feeling down, depressed - presence		ASSERTION PATTERN
	D0200B1	0	No (enter 0 in column 2)		Assertion pattern	134416003	normal mood symptoms (finding)
	D0200B1	1	Yes (enter 0-3 in column 2)		Assertion pattern	394924000	Symptoms of depression (finding)
	D0200B1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200B2		PHQ res: feeling down, depressed - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200B2	0	Never or 1 day
	D0200B2	1	2-6 Days (Several days)
	D0200B2	2	7-11 Days (Half or more of the days)
	D0200B2	3	12-14 Days (Nearly every day)
	D0200C1		PHQ res: trouble with sleep - presence		ASSERTION PATTERN
	D0200C1	0	No (enter 0 in column 2)		Assertion pattern	433206003	able to sleep (finding)
	D0200C1	1	Yes (enter 0-3 in column 2)		Assertion pattern	301345002	difficulty sleeping (finding)
	D0200C1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200C2		PHQ res: trouble with sleep - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200C2	0	Never or 1 day
	D0200C2	1	2-6 Days (Several days)
	D0200C2	2	7-11 Days (Half or more of the days)
	D0200C2	3	12-14 Days (Nearly every day)
	D0200D1		PHQ res: feeling tired/ little energy - presence		ASSERTION PATTERN
	D0200D1	0	No (enter 0 in column 2)		Assertion pattern	248272003	energy (finding)
	D0200D1	1	Yes (enter 0-3 in column 2)		Assertion pattern	248274002	lack of energy (finding)
	D0200D1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200D2		PHQ res: feeling tired/ little energy - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200D2	0	Never or 1 day
	D0200D2	1	2-6 Days (Several days)
	D0200D2	2	7-11 Days (Half or more of the days)
	D0200D2	3	12-14 Days (Nearly every day)
	D0200E1		PHQ res: poor appetite or overeating - presence		ASSERTION PATTERN
	D0200E1	0	No (enter 0 in column 2)		Assertion pattern	161825005	appetite normal (finding)
	D0200E1	1	Yes (enter 0-3 in column 2)		Assertion pattern	51575000	abnormal food appetite (finding)
	D0200E1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200E2		PHQ res: poor appetite or overeating - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200E2	0	Never or 1 day
	D0200E2	1	2-6 Days (Several days)
	D0200E2	2	7-11 Days (Half or more of the days)
	D0200E2	3	12-14 Days (Nearly every day)
	D0200F1		PHQ res: feeling bad about self - presence		ASSERTION PATTERN
	D0200F1	0	No (enter 0 in column 2)		Assertion pattern	280948003	normal sense of identity (finding)
	D0200F1	1	Yes (enter 0-3 in column 2)		Assertion pattern	267077006	loss of self-esteem (finding)
	D0200F1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200F2		PHQ res: feeling bad about self - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200F2	0	Never or 1 day
	D0200F2	1	2-6 Days (Several days)
	D0200F2	2	7-11 Days (Half or more of the days)
	D0200F2	3	12-14 Days (Nearly every day)
	D0200G1		PHQ res: trouble concentrating - presence		ASSERTION PATTERN
	D0200G1	0	No (enter 0 in column 2)		Assertion pattern	134419005	normal concentration (finding)
	D0200G1	1	Yes (enter 0-3 in column 2)		Assertion pattern	26329005	poor concentration (finding)
	D0200G1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200G2		PHQ res: trouble concentrating - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200G2	0	Never or 1 day
	D0200G2	1	2-6 Days (Several days)
	D0200G2	2	7-11 Days (Half or more of the days)
	D0200G2	3	12-14 Days (Nearly every day)
	D0200H1		PHQ res: slow, fidgety, restless - presence		ASSERTION PATTERN
	D0200H1	0	No (enter 0 in column 2)		Assertion pattern	276416006	good control of movement (finding)
	D0200H1	1	Yes (enter 0-3 in column 2)		Assertion pattern	162221009	restlessness (finding)
	D0200H1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200H2		PHQ res: slow, fidgety, restless - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200H2	0	Never or 1 day
	D0200H2	1	2-6 Days (Several days)
	D0200H2	2	7-11 Days (Half or more of the days)
	D0200H2	3	12-14 Days (Nearly every day)
	D0200I1		PHQ res: thoughts better off dead - presence		ASSERTION PATTERN
	D0200I1	0	No (enter 0 in column 2)		Assertion pattern	225446002	positive self thoughts (finding)
	D0200I1	1	Yes (enter 0-3 in column 2)		Assertion pattern	102911000	thoughts of self harm (finding)
	D0200I1	9	No response (leave column 2 blank)		Assertion pattern	288766003	does not communicate feelings (finding)
	D0200I2		PHQ res: thoughts better off dead - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0200I2	0	Never or 1 day
	D0200I2	1	2-6 Days (Several days)
	D0200I2	2	7-11 Days (Half or more of the days)
	D0200I2	3	12-14 Days (Nearly every day)
	D0300		PHQ res: total mood severity score			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	D0350		PHQ res: safety notification			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	D0350	0	No
	D0350	1	Yes
	D0500A1		PHQ staff: little interest or pleasure - presence		ASSERTION PATTERN
	D0500A1	0	No (enter 0 in column 2)		Assertion pattern	134417007	level of mood - normal (finding)
	D0500A1	1	Yes (enter 0-3 in column 2)		Assertion pattern	247753000	loss of interest (finding)
	D0500A2		PHQ staff: little interest or pleasure - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500A2	0	Never or 1 day
	D0500A2	1	2-6 Days (Several days)
	D0500A2	2	7-11 Days (Half or more of the days)
	D0500A2	3	12-14 Days (Nearly every day)
	D0500B1		PHQ staff: feeling down, depressed - presence		ASSERTION PATTERN
	D0500B1	0	No (enter 0 in column 2)		Assertion pattern	134416003	normal mood symptoms (finding)
	D0500B1	1	Yes (enter 0-3 in column 2)		Assertion pattern	394924000	Symptoms of depression (finding)
	D0500B2		PHQ staff: feeling down, depressed - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500B2	0	Never or 1 day
	D0500B2	1	2-6 Days (Several days)
	D0500B2	2	7-11 Days (Half or more of the days)
	D0500B2	3	12-14 Days (Nearly every day)
	D0500C1		PHQ staff: trouble with sleep - presence		ASSERTION PATTERN
	D0500C1	0	No (enter 0 in column 2)		Assertion pattern	433206003	able to sleep (finding)
	D0500C1	1	Yes (enter 0-3 in column 2)		Assertion pattern	301345002	difficulty sleeping (finding)
	D0500C2		PHQ staff: trouble with sleep - frequency
	D0500C2	0	Never or 1 day
	D0500C2	1	2-6 Days (Several days)
	D0500C2	2	7-11 Days (Half or more of the days)
	D0500C2	3	12-14 Days (Nearly every day)
	D0500D1		PHQ staff: feeling tired/little energy - presence		ASSERTION PATTERN
	D0500D1	0	No (enter 0 in column 2)		Assertion pattern	248272003	energy (finding)
	D0500D1	1	Yes (enter 0-3 in column 2)		Assertion pattern	248274002	lack of energy (finding)
	D0500D2		PHQ staff: feeling tired/little energy - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500D2	0	Never or 1 day
	D0500D2	1	2-6 Days (Several days)
	D0500D2	2	7-11 Days (Half or more of the days)
	D0500D2	3	12-14 Days (Nearly every day)
	D0500E1		PHQ staff: poor appetite or overeating - presence		ASSERTION PATTERN
	D0500E1	0	No (enter 0 in column 2)		Assertion pattern	161825005	appetite normal (finding)
	D0500E1	1	Yes (enter 0-3 in column 2)		Assertion pattern	51575000	abnormal food appetite (finding)
	D0500E2		PHQ staff: poor appetite or overeating - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500E2	0	Never or 1 day
	D0500E2	1	2-6 Days (Several days)
	D0500E2	2	7-11 Days (Half or more of the days)
	D0500E2	3	12-14 Days (Nearly every day)
	D0500F1		PHQ staff: feeling bad about self - presence		ASSERTION PATTERN
	D0500F1	0	No (enter 0 in column 2)		Assertion pattern	280948003	normal sense of identity (finding)
	D0500F1	1	Yes (enter 0-3 in column 2)		Assertion pattern	267077006	loss of self-esteem (finding)
	D0500F2		PHQ staff: feeling bad about self - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500F2	0	Never or 1 day
	D0500F2	1	2-6 Days (Several days)
	D0500F2	2	7-11 Days (Half or more of the days)
	D0500F2	3	12-14 Days (Nearly every day)
	D0500G1		PHQ staff: trouble concentrating - presence		ASSERTION PATTERN
	D0500G1	0	No (enter 0 in column 2)		Assertion pattern	134419005	normal concentration (finding)
	D0500G1	1	Yes (enter 0-3 in column 2)		Assertion pattern	26329005	poor concentration (finding)
	D0500G2		PHQ staff: trouble concentrating - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500G2	0	Never or 1 day
	D0500G2	1	2-6 Days (Several days)
	D0500G2	2	7-11 Days (Half or more of the days)
	D0500G2	3	12-14 Days (Nearly every day)
	D0500H1		PHQ staff: slow, fidgety, restless - presence		ASSERTION PATTERN
	D0500H1	0	No (enter 0 in column 2)		Assertion pattern	276416006	good control of movement (finding)
	D0500H1	1	Yes (enter 0-3 in column 2)		Assertion pattern	162221009	restlessness (finding)
	D0500H2		PHQ staff: slow, fidgety, restless - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500H2	0	Never or 1 day
	D0500H2	1	2-6 Days (Several days)
	D0500H2	2	7-11 Days (Half or more of the days)
	D0500H2	3	12-14 Days (Nearly every day)
	D0500I1		PHQ staff: thoughts better off dead - presence		ASSERTION PATTERN
	D0500I1	0	No (enter 0 in column 2)		Assertion pattern	225446002	positive self thoughts (finding)
	D0500I1	1	Yes (enter 0-3 in column 2)		Assertion pattern	102911000	thoughts of self harm (finding)
	D0500I2		PHQ staff: thoughts better off dead - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500I2	0	Never or 1 day
	D0500I2	1	2-6 Days (Several days)
	D0500I2	2	7-11 Days (Half or more of the days)
	D0500I2	3	12-14 Days (Nearly every day)
	D0500J1		PHQ staff: short-tempered - presence		ASSERTION PATTERN
	D0500J1	0	No (enter 0 in column 2)		Assertion pattern	285848000	able to control anger (finding)
	D0500J1	1	Yes (enter 0-3 in column 2)		Assertion pattern	248012001	temper problem (finding)
	D0500J2		PHQ staff: short-tempered - frequency			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD
	D0500J2	0	Never or 1 day
	D0500J2	1	2-6 Days (Several days)
	D0500J2	2	7-11 Days (Half or more of the days)
	D0500J2	3	12-14 Days (Nearly every day)
	D0600		PHQ staff: total mood score			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	D0650		PHQ staff: safety notification			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	D0650	0	No
	D0650	1	Yes

Section	CMS Question ID	Answer	CMS Description Light Orange Shading Indicates Start of New Question per CMS Data Dictionary	General Guidance	Mapping Based on the Following Pattern for Representation of Data Element	SNOMED CT Code	SNOMED CT Fully Specified Name	ICD-9-CM Code - Section 1 Only	ICD-10-CM Code - Section 1 Only	CDC Race & Ethnicity Codes*	Codes for Vaccines Administered (CVX) - Section O Only
E			Behavior
	E0100A		Psychosis: hallucinations		Assertion pattern	7011001	hallucinations (finding)
	E0100B		Psychosis: delusions		Assertion pattern	2073000	delusions (finding)
	E0100Z		Psychosis: none of the above		Assertion pattern	247700009	normal perception (finding)
	E0200A		Physical behav symptoms directed toward others		ASSERTION PATTERN
	E0200A	0	Behavior not exhibited		Assertion pattern	51746009	normal behavior (finding)
	E0200A	1	Behavior of this type occurred 1 to 3 days		Assertion pattern	225480004	physically abusive behavior (finding)
	E0200A	2	Behavior of this type occurred 4 to 6 days, but less than daily		Assertion pattern	225480004	physically abusive behavior (finding)
	E0200A	3	Behavior of this type occurred daily		Assertion pattern	225480004	physically abusive behavior (finding)
	E0200B		Verbal behav symptoms directed toward others		ASSERTION PATTERN
	E0200B	0	Behavior not exhibited		Assertion pattern	51746009	normal behavior (finding)
	E0200B	1	Behavior of this type occurred 1 to 3 days		Assertion pattern	225478005	verbally abusive behavior (finding)
	E0200B	2	Behavior of this type occurred 4 to 6 days, but less than daily		Assertion pattern	225478005	verbally abusive behavior (finding)
	E0200B	3	Behavior of this type occurred daily		Assertion pattern	225478005	verbally abusive behavior (finding)
	E0200C		Other behav symptoms not directed toward others		ASSERTION PATTERN
	E0200C	0	Behavior not exhibited		Assertion pattern	51746009	normal behavior (finding)
	E0200C	1	Behavior of this type occurred 1 to 3 days			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.
	E0200C	2	Behavior of this type occurred 4 to 6 days, but less than daily			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.
	E0200C	3	Behavior of this type occurred daily			Concept Not Mapped (Reason #4) -- Negated/frequency/ qualifier data elements addressed through the vendor information model or in the CCD.
	E0300		Overall presence of behavioral symptoms			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	E0300	0	No
	E0300	1	Yes
	E0500A		Behav symptoms put res at risk for illness/injury		ASSERTION PATTERN
	E0500A	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0500A	1	Yes		Assertion pattern	81763001	at risk for injury (finding)
	E0500B		Behav symptoms interfere with resident care		ASSERTION PATTERN
	E0500B	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0500B	1	Yes			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	E0500C		Behav symptoms interfere with social activities		ASSERTION PATTERN
	E0500C	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0500C	1	Yes		Assertion pattern	88598008	impaired social interaction (finding)
	E0600A		Behav symptoms put others at risk for injury		ASSERTION PATTERN
	E0600A	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0600A	1	Yes		Assertion pattern	391155006	at risk of harming others (finding)
	E0600B		Behav symptoms intrude on privacy of others		ASSERTION PATTERN
	E0600B	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0600B	1	Yes			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	E0600C		Behav symptoms disrupt care or living environment		ASSERTION PATTERN
	E0600C	0	No		Assertion pattern	51746009	normal behavior (finding)
	E0600C	1	Yes			Concept Not Mapped (Reason #2) -- No comparable SNOMED CT concept is available for either 1:1 equivalent or most proximal parent mapping
	E0800		Rejection of care: presence and frequency		QUESTION/ ANSWER PATTERN	405078008	compliance behavior (observable entity)
	E0800	0	Behavior not exhibited		Question/Answer pattern	386673006	does comply with treatment (finding)
	E0800	1	Behavior of this type occurred 1 to 3 days		Question/Answer pattern	105480006	refusal of treatment by patient (situation)
	E0800	2	Behavior of this type occurred 4 to 6 days, but less than daily		Question/Answer pattern	105480006	refusal of treatment by patient (situation)
	E0800	3	Behavior of this type occurred daily		Question/Answer pattern	105480006	refusal of treatment by patient (situation)
	E0900		Wandering: presence and frequency		QUESTION/ ANSWER PATTERN	363896009	behavior observable (observable entity)
	E0900	0	Behavior not exhibited		Question/Answer pattern	51746009	normal behavior (finding)
	E0900	1	Behavior of this type occurred 1 to 3 days		Question/Answer pattern	50239007	wandering (finding)
	E0900	2	Behavior of this type occurred 4 to 6 days, but less than daily		Question/Answer pattern	50239007	wandering (finding)
	E0900	3	Behavior of this type occurred daily		Question/Answer pattern	50239007	wandering (finding)