The United States Core Data for Interoperability (USCDI) is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. Data reflecting SDOH the conditions in which people live, learn, work, and play remains much more limited across healthcare. There is a growing recognition that by capturing and accessing SDOH data during the course of care, providers can more easily address non-clinical factors, such as food, housing, and transportation insecurities, which can have a profound impact on a elements for potential inclusion in the USCDI in the future.
Specifically, this is a one-year project that will inform: of tools and resources, such as updates to the Health IT Playbook, to assist health care providers with documenting and acting upon SDOH data specifically as it pertains to use of the open notes (EHR).;
information including SDOH data that is noted in the clinical notes section of the patient portal; and are important to capture and exchange for future data standardization efforts; such as USCDI expansion.
Through qualitative data collection, this one-year project will collect information from health care providers (including behavioral health DOH data collection and exchange. ONC seeks to obtain information from health care providers and patients to understand:
- To what extent do health care providers document and use SDOH information to treat a patient or offer referral services
- How do health care providers leverage open text fields to document SDOH data, specifically clinical notes and assessments section of an EHR to document SDOH data;
- Challenges clinicians experience when using SDOH data; including data captured in open text fields;
- The types of SDOH data that individuals want to collect, share and use;
OpenNotes is an organization committed to spreading the availability of open visit notes and studying the effects.
OpenNotes does not sell software or other products. However, they produce tools and research designed to improve access and use of clinical notes.
Unlike other non-profit research organizations, OpenNotes provides specialized and exclusive expertise in researching the use of clinical notes from the clinician and patient perspective. OpenNotes has published a number of research products exploring how patients and clinicians leverage visit notes.