Att3c_EHR

[NCHHSTP] TRANSCEND: Transgender Status-neutral Community-to-clinic Models to End the HIV Epidemic

Att3c_EHR

OMB: 0920-1410

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Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX









TRANSCEND: Transgender Status-neutral Community-to-clinic Models to End the HIV Epidemic





Attachment 3c

EHR Data Variables

















Public reporting burden of this collection of information is estimated to average 8 hours per response from each recipient data manager, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)




Data to be extracted from the Electronic Health Record


Number

Data element

Source

Description

Required/Optional to Report with CDC

A

Lab Testing Data from Clinic 

This module will be applied to all relevant tests for HIV and other sexually transmitted infections.

A1

Date of test

EHR 

Date 

Required 

A2

Name of test

EHR 

Text

Required 

A3

Procedure code 

EHR

CPT/HCPCS/ICD-10-PCS

Required 

A4

Test code 

EHR 

LOINC code/Quest code 

Required 

A5

Test result code 

EHR 

LOINC code 

Required 

A6

Type of test (in-house test)

EHR 

Text, customized by clinics

Ex (Point-of-care antigen/antibody) 


Required 

A7

Test result code (in-house)

EHR

LOINC code/Any standard results

Required 

A8

Test result, numeric

EHR

Number

Required 

A9

Test result unit, for numeric result 

EHR 

Unit of result

Required 

A10

Test result, text 

EHR 

Any result recorded in text format

Required 

A11

Test result interpretation 

EHR 

Text

Optional

B

Prescription (Rx) Data from Clinic 

This module will be applied to all prescriptions relevant for HIV prevention or treatment, STI treatment, gender-affirming hormone therapy.

B1

Date of Rx 

EHR 

Date

Required 

B2

NDC code of Rx

EHR

11 digit code

Required 

B3

Number of prescribed units of medicine

EHR 

Number

Required

B4

Unit of medicine

EHR

Bottle/Box/Vial/ml/gram, ect

Required

B5

Days of supply prescribed 

EHR 

Number 

Required 

B6

Diagnosis associated with Rx

EHR 

ICD-10

Required

B7

Reason for Rx

EHR

Free text

Optional

B8

Prescriber NPI

EHR

Number

Optional

C

Clinical Visit 

 This module will be applied to all encounters for general clinic services.

C1

Date of encounter 

EHR 

Date 

Required 

C2

Reason for visit

EHR 

Text 

Required 

C3

Diagnosis code for encounter

EHR

ICD-10 CM

Required 

C4

Procedure code for encounter

EHR

CPT/HCPCS/ICD-10-PCS

Required 

C5

Procedure extension code

EHR


Required 

C6

Clinical notes

EHR

Any additional notes

Optional

C7

Referral for Clinical Services

EHR

Referral code or free text

Required

C8

Referral Reason

EHR

Free text

Required



Data to be collected from client intake forms, clinic EHR, CBO, other sources


Number

Variables Category and Name

Source

Categories

Required/Optional to Report to CDC

D

Demographic and Behavioral Information


D1

Unique ID

Client Intake Form

Numeric free text

Required

D2

Year of birth

Client Intake Form

Numeric free text

Required

D3

Date intake form completed

Client Intake Form

Date

Required

D4

Race

Client Intake Form

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Unknown/not answered


Required

D5

Ethnicity

Client Intake Form

Hispanic or Latino/a

Not Hispanic or Latino/a

Unknown/not answered

Required

D6

Gender Identity

Client Intake Form

Male

Female

Transgender male

Transgender female

Non-binary/ genderqueer

Another gender identity

Unknown/not answered


Required

D7

Sex assigned at birth

Client Intake Form

Male

Female

Unknown/not answered


Required

D8

Sex in the past 6 months

Client Intake Form

Yes

No

Not answered

Required

D9

Type of sex in the past 6 months

Client Intake Form

(check all that apply)

Receptive anal sex

Insertive anal sex

Receptive vaginal sex

Insertive vaginal sex

Receptive oral sex

Insertive oral sex

Not answered

Required

D10

Used condoms in the past 6 months

Client Intake Form

Always

Sometimes

Never

Not answered

Required

D11

Number of sex partners in the past 6 months

Client Intake Form

Numeric

Required

D12

Sex with a person with HIV in past 6 months

Client Intake Form

Yes

No

Unknown

Required

D13

Injection drug use behavior in the past 6 months

Client Intake Form

Yes

No

Not answered

Required

D14

If yes to injection drug use in the past 6 months, shared any injection equipment?

Client Intake Form

Yes

No

Not answered

Required

D15

Substance use in the past 6 months

Client Intake Form

(check all that apply)

Alcohol

Marijuana

Methamphetamine

Cocaine

Opioids

Other

Not answered

Required

D16

Current use of hormone therapy

Client Intake Form

Yes

No

Required

D17

If yes to hormone therapy, shared needle or syringe?

Client Intake Form

Yes

No

N/A

Optional

D18

If no, interested in using hormone therapy?

Client Intake Form

Yes

No

Required

E

Intake Information


E1

Initial intake in TRANSCEND at CBO

Client Intake Form

Yes

No

Required

E2

If yes, name of CBO

Client Intake Form

Text

Required

E3

New client at CBO

Client Intake Form

Yes

No

Required

E4

Initial intake in TRANSCEND at clinic

Client Intake Form

Yes

No

Required

E5

If yes, name of clinic

Client Intake Form

Care Resource

Callen Lorde

St. Johns

Whitman Walker Health

Other

Required

E6

New client at clinic

Client Intake Form

Yes

No

Required

E7

Reason for intake visit

Client Intake Form

Establish primary care

HIV testing

STI testing

HIV PrEP

HIV PEP

HIV treatment

Gender-affirming hormone therapy

Other gender-affirming care

Support services

Mental or behavioral health care

Substance use treatment

Other

Required

E8

Interest in services

Client Intake Form

Housing

Insurance

Transportation

Employment

Legal

Food

Other

Optional

E9

Interest in navigation

Client Intake Form

Yes

No

Required

E10

Referred to clinic at intake visit

Client Intake Form

Yes

No

Required

E11

Referral from

Client Intake Form

Free text

Optional

E12

HIV test in last 6 months

Client Intake Form

Yes

No

Required

E13

Result of most recent HIV test

Client Intake Form

Positive

Negative

Unknown

Not answered

Required

F

Referral and Service Use Information


F1

Date received service at CBO (repeating if multiple)

Clinic/CBO database

Date

Required

F2

Referred to clinic

Clinic/CBO database

Yes

No

Required

F3

Date referred to clinic

Clinic/CBO database

date

Required

F4

Referred to CBO

Clinic/CBO database

Yes

No

Optional

F5

Date referred to CBO

Clinic/CBO database

Date

Optional

F6

If referred to CBO, which CBO

Clinic/CBO database

Text

Optional

F7

If referred to CBO, for what service


Clinic/CBO database

Text

Optional

F8

Linked to CBO

Clinic/CBO database

Yes

No

Optional

G

HIV Testing Information from CBO or Community Outreach


G1

Date of HIV test

Clinic/CBO database

Date

Required

G2

Type of HIV test

Clinic/CBO database

Lab-based antigen/antibody

Point-of-care antigen/antibody

Point-of-care antibody

RNA testing

Required

G3

Result of HIV test

Clinic/CBO database

Positive/reactive

Negative

Indeterminate

Invalid

No result

Required

G4

If positive, new diagnosis

Clinic/CBO database

Yes, new diagnoses

No

Optional

G5

Referred to clinic for treatment after positive HIV test

Clinic/CBO database

Yes

No

Required

G6

Date referred for treatment after positive HIV test

Clinic/CBO database

date

Required

G7

Referred to clinic for PrEP after negative HIV test

Clinic/CBO database

Yes

No

Required

G8

Date referred to clinic for PrEP after negative HIV test

Clinic/CBO database

Date

Required

H

Navigation


H1

Offered navigation for clinic referral

Clinic/CBO database

Yes

No

Required

*if navigation services available

H2

Used navigation for clinic referral

Clinic/CBO database

Yes

No

Required

*if navigation services available





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPtomey, Natasha (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2023-09-05

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