Analysis of clinical specimens to obtain information about the health of a patient.

Data Element

Result Interpretation

Categorical assessment of a laboratory value, often in relation to a test's reference range.

Examples include but are not limited to high, low, critical high, and normal.

Applicable Vocabulary Standard(s)

Applicable Standards
  • Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2023 Release
  • HL7 Code System ObservationInterpretation


Support for HL7 observationInterpretation

APHL supports the comment by CAP ( highlighting that the HL7 observationInterpretation code system ( should be the required vocabulary used; this code system is used in ALL HL7 products (V2, CDA and FHIR). In addition allowing use of SNOMED CT with values drawn from the qualifier hierarchy is also appropriate and should be supported as optional.

CAP Comment on Result Interpretation

  • Data Class: Laboratory
  • Data Element: Result Interpretation
  • CAP Comment: The CAP applauds the ONC’s decision to add this data element to USCDI v4, as this data element represents the categorical assessment of a laboratory value (e.g. “high”, “low”, “critical”, etc.) and is required by CLIA. The CAP recommends that the HL7 interpretation code system and value set—which was in the original submission for this data element—be added as a minimum vocabulary standard for this data element. The CAP would also recommend that the ONC include SNOMED CT as a vocabulary standard for this element.

THIA Comment on Laboratory: Result Interpretation

The Texas Health Informatics Alliance (THIA) Policy and Standards Working Group supports the proposal for result interpretation; however, standardization of high, low, critical, and normal values should be explored and standardized by CAP and APHL. The definition of a critical value per institution should be kept in mind when the data is collected and there should be some level of consistency between institutions.

It is important to consider the cut-off for a critical value between various facilities. This is especially true for interpreting lab results. Every lab has to establish their own reference ranges relative to their population and instrumentation. It might be problematic or unclear how far out of the normal various labs are and if there are different levels for different institutions. Additionally, an expansive number and type of assays are performed; it is unrealistic to assume that providers know and/or are comfortable with interpreting all of them. It is important to provide interpretations.

Notably, there is a push for making data available to patients. Patients can read results before their clinicians get to them. In Epic MyChart, there is a little red eye to indicate that the clinician has not seen the results yet. However, it is unlikely that all systems have a similar feature. The requirement of a similar feature may encourage compliance.

APHL Comments on ISA 2022

APHL still supports inclusion of this data element in the Laboratory class of USCDI V4. - see also - which applies to this data element as a specialization of observation interpretation.

CAP Comment on Test Interpretation (Abnormal Flag) Data Element

Data Element: Test Interpretation (Abnormal Flag)

  • Corresponding CLIA Reporting Requirement: Test result interpretation
  • Description: The College of American Pathologists (CAP) supports this data element as written and urges that it be brought up to Level 2 and ideally included in USCDI v4. The CAP supports this data element to align with CLIA’s test result interpretation reporting requirement. The CLIA-defined reporting requirements are required for laboratory reporting and should be used as the basis for laboratory and public health reporting standards. Because laboratories already communicate test result interpretations along with reference ranges to the Centers for Medicare & Medicaid Services (CMS), this data element is already in wide usage and should be classified Level 2 at a minimum.

Log in or register to post comments