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Screening and Assessments

Introduction

Clinicians use various terms such as assessments, scales, surveys, and screenings to describe the tools and processes to collect health-related information for assessing a patient’s health-related matter. On this page, the term Screening and Assessments refer to recording responses and capturing assertions/determinations resulting from this process and these tools. This page documents how Screening and Assessments are used to identify various problems or health concerns and how US Core Profiles record Screenings and Assessments ranging from simple observations to complex structured evaluations.

The Gravity Project and its SDOH Clinical Care HL7 Implementation Guide address the screening process and related interventions to address Social Determinant of Health (SDOH). Those efforts helped guide US Core 5.0.1 updates to meet the USCDI v2 SDOH data elements for Assessments, Goals, Interventions, and Problems/Health Concerns. With the addition of the USCDI v3 Health Status/Assessments data class, US Core 6.0.0 expanded the guidance from an SDOH only focus to a general framework of Screenings and Assessments for all domains, including:

• SDOH
• Functional Status
• Disability Status
• Mental/Cognitive Status.

However, implementers SHOULD consider more constrained, domain-specific profiles derived from the US Core Profiles to meet the needs of their respective use cases.

Related Activities in Clinical Care

The figure below shows how screening and assessments lead to providing services for a patient.

• Screening and Assessments: Screening and Assessment are used to identify problems before delivering appropriate clinical care. The following US Core Profiles support capturing their responses:
  • US Core Simple Observation Profile
  • The US Core Observation Screening Assessment Profile
  • The SDC Base Questionnaire/US Core QuestionnaireResponse Profile
• Problems/Health Concerns: The identified health-related conditions (for example, homelessness or disability) are represented by:
  • US Core Simple Observation Profile
  • US Core Condition Problems and Health Concerns Profile.
• Interventions: The US Core ServiceRequest Profile communicates services offered to patients to address problems/health concerns. The US Core Procedure Profile can also record a completed service or intervention.
• Goals: Identifying and defining a future desired condition or change in condition (for example, Has adequate quality meals and snacks) is represented by US Core Goal Profile.

Screening and Assessments

Screening and Assessments are used to identify various problems or health concerns. Their complexity ranges from simple observations to complex structured evaluations:

• Clinician makes a simple observation - (for example, the patient states they are homeless)
• Clinician administers a survey to gather information (for example, the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Survey)
• Clinician makes a “clinical judgment” based on an assessment tool. (for example, based on the PRAPARE survey, the patient has a lack of access to transportation)

The following guidance was developed after reviewing several functional status, disability status, mental/cognitive status, and SDOH screening and assessment tools.

Clinical Judgments

Whether based on simple observations or detailed assessments, clinicians may record clinical judgments as:

• a problem or health concern
• as observation

Local policies guide what is appropriate for the problem list versus an observation. For example, some clinics may consider social needs as sensitive information and not appropriate for the problem list. Observations can contribute to the identification of future problems or health concerns and support service requests and procedures.

Every server that supports the USDCI Data Class “Health Status/Assessments”:

• SHALL support representing clinical judgments using US Core Condition Problems and Health Concerns Profile or US Core Simple Observation Profile.
• When a Simple Observation or Problem or Health Concern is recorded based on a structured screening an assessment (see below), the US Core Simple Observation Profile SHOULD reference it using the derivedFrom element and the US Core Condition Problems and Health Concerns Profile using the evidence.detail element,

Structured Screening and Assessments

Screening and Assessments can be structured survey instruments consisting of questions with a variety of response including true/false, coded, textual, and multiple choice. Examples include PRAPARE, APGAR score and PHQ-9. US Core defines two ways to represent the questions and responses to these screening and assessment instruments:

• Observation: US Core Observation Screening Assessment Profile
• Questionnaire/QuestionnaireResponse: SDC Base Questionnaire/US Core QuestionnaireResponse Profile

Systems SHOULD support all three profiles for USDCI Data Class Health Status/Assessments. The table below summarizes the differences in conformance requirements for these profiles between version 5.0.1 and 6.0.0 of US Core

The sections below provide additional guidance on when Observations and Questionnaire/QuestionnaireResponse can be used to represent the structured screenings and assessments.

US Core Observation Screening Assessment Profile

US Core Observation Screening Assessment Profile is defined to record observations from responses to screening tools and assessments used for any context (e.g., SDOH, functional status, etc.). Although systems can represent most questions and answers in healthcare assessments as FHIR Observations, it is only sometimes necessary and appropriate to represent all of them as Observations. Only relevant responses should be extracted as Observations. For example, depending on the use case and focus of the Assessment or Survey, patient demographic information may be recorded in the Patient resource instead of Observations. The observations can be grouped and nested to preserve the structure of screening or assessment instruments. The figure below illustrates the relationship between the Observation screening and assessments “panel” and the individual screening and assessment “item” Observations. Each box represents an Observation:

Note that the panels can be nested to create additional groupings of responses. See the US Core Observation Screening Assessment Profile page for detailed documentation on how the observations are linked, examples, and search requirements.

Searching for Screening and Assessment Data

Unlike QuestionnaireResponse, When Observations are used to record set of Screening and Assessments responses, clients can query individual responses using the standard FHIR RESTful API search parameters Below is a simple example of a FHIR RESTful search transaction on Observation to access a patient’s SDOH assessment data

Click on Here To See Search Example

User-Agent: python-requests/2.25.1
Accept-Encoding: gzip, deflate
Accept: application/fhir+json
Connection: keep-alive
Content-Type: application/fhir+json

Connection: keep-alive
Content-Location: http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=sdoh
Content-Type: application/fhir+json;charset=utf-8
Content-Length: 4112
Date: Sun, 21 Nov 2021 03:15:18 GMT

{
  "resourceType": "Bundle",
  "id": "158f4b97-5b3a-4363-81da-19d454a6df30",
  "meta": {
    "versionId": "1",
    "lastUpdated": "2021-11-20T22:15:18.726-05:00"
  },
  "type": "searchset",
  "total": 1,
  "link": [
    {
      "relation": "self",
      "url": "http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=sdoh"
    }
  ],
  "entry": [
    {
      "fullUrl": "http://wildfhir4.aegis.net/fhir4-0-1/Observation/hunger-question-example",
      "resource": {
        "resourceType": "Observation",
        "id": "hunger-question-example",
        "meta": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-name",
              "valueString": "Hunger Question Example"
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-description",
              "valueMarkdown": "This is a Hunger Question Example for the *US Core Screening Response Observation Profile*."
            }
          ],
          "versionId": "1",
          "lastUpdated": "2021-11-20T22:13:54.070-05:00",
          "profile": [
            "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response"
          ]
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>meta</b>:       \n      </p><p><b>status</b>: FINAL      \n      </p><p><b>category</b>: SDOH         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'sdoh' = 'sdoh', given as 'SDOH'})</span>, Survey         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'survey' = 'Survey', given as 'Survey'})</span></p><p><b>code</b>: Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '88122-7' = 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]', given as 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]'})</span></p><p><b>subject</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>effective</b>: Nov 12, 2021 8:59:15 PM      \n      </p><p><b>performer</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>value</b>: Often true         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'LA28397-0' = 'Often true', given as 'Often true'})</span></p><p><b>derivedFrom</b>: Hunger Vital Signs Questionnaire      \n      </p></div>"
        },
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://loinc.org",
                "code": "sdoh",
                "display": "SDOH"
              }
            ]
          },
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                "code": "survey",
                "display": "Survey"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "88122-7",
              "display": "Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]"
            }
          ]
        },
        "subject": {
          "reference": "Patient/example"
        },
        "effectiveDateTime": "2021-11-12T17:59:15-08:00",
        "performer": [
          {
            "reference": "Patient/example"
          }
        ],
        "valueCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "LA28397-0",
              "display": "Often true"
            }
          ]
        },
        "derivedFrom": [
          {
            "display": "Hunger Vital Signs Questionnaire"
          }
        ]
      },
      "search": {
        "mode": "match",
        "score": 1
      }
    }
  ]
}

SDC Base Questionnaire/US Core QuestionnaireResponse Profile

Screening and assessment instruments may be represented as questionnaires including FHIR Questionnaires. The Structured Data Capture (SDC) specification documents the workflow for the creation, discovery and retrieval and data-extraction of FHIR Questionnaire and QuestionnaireResponse. The US Core QuestionnaireResponse Profile is based on the Structured Data Capture (SDC) Questionnaire Response Profile), and is used to capture, exchange and persist the response data. QuestionnaireResponse can be thought of as a snapshot of the filled-out answer forms to the screening and assessment questions represented in the SDC Base Questionnaire. It is ordered and grouped corresponding to the Questionnaire and can be consulted when a complete and accurate record of the responses is required. the US Core QuestionnaireResponse Profile page for detailed documentation, examples and search requirements.

Extracting US Core Observation Screening Assessment from US Core QuestionnaireResponse

US Core Observation Screening Assessment can be extracted from US Core QuestionnaireResponse. Although QuestionnaireResponse can be searched using the standard FHIR RESTful API search parameters, individual responses are not directly searchable in QuestionnaireResponse. In order to search directly for individual responses, the QuestionnaireResponse must be “parsed” into a searchable form - i.e. to a local FHIR or non-FHIR data store such as a database or FHIR Observations. Both SDC and the SDOH Clinical Care implementation guide define how data captured in a QuestionnaireResponse can be extracted and used to create or update Observations or other FHIR resources.

Choosing Between QuestionnaireResponse and Observation

For API developers using US Core, it’s important to understand when to use the QuestionnaireResponse versus Observation to represent structured assessments and surveys. Here are some guidelines to help choose the appropriate profile:

• Observations represent specific point-in-time facts that need to be searched, trended, be the subject of statistical analysis and/or directly referenced in support of other actions. Not all answers in a form will necessarily be appropriate to surface as an Observation. However, anything that meets one of the preceding criteria will need to be surfaced as an Observation.
• QuestionnaireResponses represent the source-of-truth of a completed form. QuestionnaireResponse shows how the question was phrased, what answer text was seen or typed, the order in which the survey or assessment was completed, etc. For FHIR implementers, it is important to note that QuestionnaireResponse references specific versions of a form filled out whether the form was represented as a FHIR Questionnaire or not. (however, it may be challenging to determine canonical URLs and linkIds that are consistent across systems without using a FHIR Questionnaire.) This reference provides the context of exactly what options were available to choose from, what logic was used to calculate answers, or to determine what questions were asked. It is important to note that QuestionnaireResponse cannot be used for searching based on individual responses but can be used to capture higher-level information such as what form was filled out, by whom, and when.

In many cases, data might be represented using both mechanisms - the initial raw assessment retained for audit or detailed review stored as a QuestionnaireResponse, and the detailed key answers surfaced as Observations for easy search and analysis.

Terminology

Category Codes

API consumers may select contextual categories (for example, SDOH) when accessing patient information. For example, the US Core Category Code System provides categories for:

• US Core Simple Observation Profile
• US Core Observation Screening Assessment Profile
• US Core Condition Problems and Health Concerns Profile
• US Core ServiceRequest Profile

Each profile’s Quick Start section shows searches by category. Although not defined in US Core Procedure, implementers can categorize procedures using US Core Category or infer the context by inspecting the referenced ServiceRequest. Similarly, they can review the Questionnaire’s metadata to determine US Core QuestionnaireResponse’s context.

Clients need to understand that data categorization is somewhat subjective. The categorization applied by the source may not align with the client’s expectations. Clients may find it more beneficial to use queries based on a specific code or set of codes or to perform additional client-side filtering of query results.

Codes for Problems/HealthConcerns, Goals, Service Requests, and Procedures

US Core uses broadly defined value sets that contain concepts used across use cases, including SDOH. For the SDOH Clinical Care HL7 Implementation Guide, the Gravity Project has defined “Grouped Value Sets” across specific social risk factor domains for problems/health concerns, goals, procedures, and service requests. Value sets for each SDOH domain are bundled together to create the groupings. The links below are to these Gravity Project-managed value sets in Value Set Authority Center (VSAC). In VSAC, clicking “Grouping Members” within the Value Set Details tab will present the many individual value sets in the group representing the various SDOH domains. These grouped value sets are narrower subsets of the value sets allowed in the respective US Core Profiles. However, when recording SDOH data US Core Profiles, servers SHOULD use them.

• Social Determinants of Health Conditions Value Set
• Social Determinants of Health Procedures Value Set
• Social Determinants of Health Goals Value Set
• Social Determinants of Health Service Requests Value Set

The figure below illustrates how the Gravity value sets are grouped for use in the US Core Condition Problems and Health Concerns Profile and how the grouped value set is compatible with the broader US Core Problem code value set.