ONC Adds 20 New Data Elements to USCDI v4 to Drive Interoperability

Allergies and Intolerances

Prior versions of USCDI have included data elements for Substance (Medication) and Substance (Drug Class). ONC received feedback that standardized data are needed to represent non-medication substances, including common allergens like latex, peanuts, and eggs. To address this, ONC added a new data element, Substance (Non-Medication), to the Allergies and Intolerances data class.

Encounter Information

USCDI v3 included several data elements in a new data class Encounter Information. Several stakeholders noted the need for a data element to link data related to an encounter, such as diagnosis and medications prescribed. To address these comments, ONC added Encounter Identifier as a data element to USCDI v4.

Goals and Preferences

Including a patient’s goals and preferences in care planning is essential to person-centered care. ONC officials noted that the care planning process may include expressions of interventions, religious beliefs, and overall care preferences.

To make these preferences available for exchange, ONC added two data elements to this data class: Treatment Intervention Preference and Care Experience Preference. Due to their similarities, the data representing goals and preferences warranted inclusion in a single data class, so ONC renamed the Goals data class to “Goals and Preferences.”

Health Status Assessments

ONC added three data elements to the Health Status Assessments data class to develop the use and exchange of data elements that represent structured assessments. The new elements include Alcohol Use, Substance Use, and Physical Activity.

In addition to these changes, ONC moved SDOH Assessment to this data class because it is represented by the same vocabulary standards as the three new data elements.

Laboratory

ONC added six data elements to the Laboratory data class: Result Unit of Measure; Result Reference Range; Result Interpretation; Specimen Condition Acceptability; Specimen Source Site; and Specimen Identifier.

The first three data elements support public health reporting needs and provide patients and providers with more details for interpreting laboratory data. The latter three elements add more specificity to laboratory specimens.

Medications

USCDI users have provided ongoing support for including data elements that represent the exchange of patient medication information.

While ONC added Medications data elements in USCDI v3, the additions did not address the extent to which patients take their medications based on clinical instructions. To address this, ONC added Medication Instructions and Medication Adherence as two data elements in USCDI v4.

Medication Adherence includes patient-reported data, further enhancing patient engagement.

“These two data elements can also be used to support medication reconciliation by providing a fuller picture of all prescription and over-the-counter medications, supplements, herbals, and other substances a patient is taking,” ONC officials wrote.

Procedures

Capturing and sharing when procedures occur is critical. For this reason, ONC added Performance Time to the Procedures data class.

Vital Signs

ONC added one element to the Vital Signs data class: Average Blood Pressure.

Average Blood Pressure is an independent risk factor in many diseases and health conditions.

“The time period, number of readings, and specific protocols may be needed to interpret an Average Blood Pressure value,” ONC officials emphasized.