ONC releases USCDI Version 5 to drive interoperability

Observations

Under the Observation data class, ONC added two data elements: Advance Directive Observation and Sex Parameter for Clinical Use (SPCU).

Advance Directive Observation describes various characteristics of an advance directive document, including its existence, location, content and validity.

The SPCU data element gives sex-specific context to observations, tests, procedures and results.

Individuals with SPCU attributes of female or male can have different reference ranges for various laboratory test results, different expected findings on diagnostic imaging studies and varying stages of gender-affirming treatment.

The HTI-1 Final Rule's update to the "patient demographics and observations" certification criterion includes the SPCU data element.

Orders

ONC proposed to add an Orders data class and an Order data element in Draft USCDI v5. While ONC received public support for adding the new Orders data class, the agency also received feedback that the single Order data element was too broad to represent various order types.

In response to this input, ONC added five data elements representing the following order types: Medication, Laboratory, Diagnostic Imaging, Clinical Test and Procedure.

By adding the Orders data class and five data elements to USCDI v5, ONC creates a minimum set of order types for exchange to support patient care, care planning and case management.

Additional data elements

ONC added data elements across several existing USCDI data classes.

Within the Clinical Notes class, ONC added the following:

• Emergency Department Note.
• Operative Note.

In the Patient Demographics/ Information class, ONC added these:

• Interpreter Needed.
• Pronouns.
• Name to Use.

Under the Provenance data class, ONC added the following:

• Author.
• Author Role.

In the Immunizations class, ONC added a data element for Lot Number. Lastly, under the Medications class, ONC added a Route of Administration data element.

Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.