Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Content Standards for MDS and OASIS Assessment Instruments

12/01/2011

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).

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