ISA Document Table of Contents

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Vocabulary/Code Set/Terminology Standards and Implementation Specifications

A-H

Allergies and Intolerances

Representing Patient Allergic Reactions
Representing Patient Allergies and Intolerances; Environmental Substances
Representing Patient Allergies and Intolerances; Food Substances
Representing Patient Allergies and Intolerances; Medications

Clinical Notes

Representing Clinical Notes

Cognitive Status

Representing Patient Cognitive Status

Demographics

Representing Patient Contact Information for Telecommunications

Dietary and Nutritional Needs

Representing Nutrition Assessment, Diagnosis, Interventions and Monitoring/Evaluation

Emergency Medical Services

Representing Health Care Data for Emergency Medical Services

Encounter Diagnosis, Assessment and Plan

Representing Assessment and Plan of Treatment
Representing Patient Dental Encounter Diagnosis
Representing Patient Medical Encounter Diagnosis

Family Health History

Representing Patient Family Health History

Functional Status/Disability

Representing Patient Functional Status and/or Disability

Goals

Representing Patient Goals

Health Care Providers, Family Members, and Other Caregivers

Representing Health Care Providers
Representing Provider Role in Team Care Settings
Representing Relationship Between Patient and Another Person
I-P

Imaging (Diagnostics, Interventions and Procedures)

Representing Imaging Diagnostics, Interventions and Procedures

Immunizations

Representing Immunizations – Administered
Representing Immunizations – Historical

Industry and Occupation

Representing Patient Industry and Occupation

Laboratory

Representing Laboratory Tests
Representing Laboratory Values/Results

Medications

Representing Patient Medications

Nursing

Representing Clinical/Nursing Assessments
Representing Nursing Interventions
Representing Outcomes for Nursing
Representing Patient Problems for Nursing

Patient Clinical “Problems” (i.e., conditions)

Representing Patient Clinical “Problems” (i.e., Conditions)

Preferred Language

Representing Patient Preferred Language (Presently)

Pregnancy Status

Representing Patient Pregnancy Status

Procedures

Representing Dental Procedures Performed
Representing Medical Procedures Performed

Provenance

Representing Data Provenance
R-V

Race and Ethnicity

Representing Patient Race and Ethnicity

Research

Representing Data for Biomedical and Health Services Research Purposes

Sex at Birth, Sexual Orientation and Gender Identity

Representing Patient Gender Identity
Representing Patient Sex (At Birth)
Representing Patient-Identified Sexual Orientation

Social, Psychological, and Behavioral Data

Representing Alcohol Use
Representing Depression
Representing Drug Use
Representing Exposure to Violence (Intimate Partner Violence)
Representing Financial Resource Strain
Representing Food Insecurity
Representing Housing Insecurity
Representing Level of Education
Representing Physical Activity
Representing Social Connection and Isolation
Representing Stress
Representing Transportation Insecurity

Tobacco Use

Representing Patient Electronic Cigarette Use (Vaping)
Representing Patient Second Hand Tobacco Smoke Exposure
Representing Patient Tobacco Use (Smoking Status)

Units of Measure

Representing Units of Measure (For Use with Numerical References and Values)

Vital Signs

Representing Patient Vital Signs

Content/Structure Standards and Implementation Specifications

A-H

Admission, Discharge, and Transfer

Sending a Notification of a Long Term Care Patient’s Admission, Discharge and/or Transfer Status to the Servicing Pharmacy
Sending a Notification of a Patient’s Admission, Discharge and/or Transfer Status to Other Providers

Care Coordination for Referrals

Referral from Acute Care to a Skilled Nursing Facility
Referral to a Specialist - Request, Status Updates, Outcome
Referral to Extra-Clinical Services - Request, Updates, Outcome

Care Plan

Documenting and Sharing Care Plans for a Single Clinical Context
Documenting and Sharing Medication-Related Care Plans by Pharmacists
Documenting Care Plans for Person Centered Services
Domain or Disease-Specific Care Plan Standards
Sharing Patient Care Plans for Multiple Clinical Contexts

Clinical Decision Support

Communicate Appropriate Use Criteria with the Order and Charge to the Filling Provider and Billing System for Inclusion on Claims
Provide Access to Appropriate Use Criteria
Sharable Clinical Decision Support

Clinical Quality Measurement and Reporting

Reporting Aggregate Quality Data for Quality Reporting Initiatives
Reporting Patient-level Quality Data for Quality Reporting Initiatives
Sharing Quality Measure Artifacts for Quality Reporting Initiatives

Data Provenance

Establishing the Authenticity, Reliability, and Trustworthiness of Content Between Trading Partners

Diet and Nutrition

Exchanging Diet and Nutrition Orders Across the Continuum of Care

Drug Formulary & Benefits

Allows Pharmacy Benefit Payers to Communicate Formulary and Benefit Information to Prescriber Systems

Electronic Prescribing

Allows a Long Term or Post-Acute Care to Request to Send an Additional Supply of Medication
Allows a Pharmacy to Notify a Prescriber of Prescription Fill Status
Allows a Pharmacy to Request a Change to a Prescription
Allows a Pharmacy to Request a New Prescription For a New Course of Therapy or to Continue Therapy
Allows a Pharmacy to Request Additional Refills
Allows a Pharmacy to Request, Respond to, or Confirm a Prescription Transfer
Allows a Prescriber or a Pharmacy to Request a Patient’s Medication History
Allows a Prescriber to Cancel a Prescription
Allows a Prescriber to Communicate Drug Administration Events
Allows a Prescriber to Communicate with a REMS Administrator
Allows a Prescriber to Prescribe Medication Using Weight-Based Dosing
Allows a Prescriber to Recertify the Continued Administration of a Medication Order
Allows a Prescriber to Request, Cancel or Appeal Prior Authorization for Medications
Allows a Prescriber to Send a New Prescription to a Pharmacy
Allows a Prescriber to Send a Prescription to a Pharmacy for a Controlled Substance
Allows a Provider to Request a Patient’s Medication History from a State Prescription Drug Monitoring Program (PDMP)
Allows for Communication of Prescription Information Between Prescribers and Dispensers
Allows for the Exchange of State Prescription Drug Monitoring Program (PDMP) Data

Family Health History (Clinical Genomics)

Representing Family Health History for Clinical Genomics

Healthy Weight

Sending Healthy Weight Information
I-P

Images

Format of Medical Imaging Reports for Exchange and Distribution
Format of Radiation Exposure Dose Reports for Exchange and Distribution
Format of Radiology Reports for Exchange and Distribution
Medical Image Formats for Data Exchange and Distribution

Laboratory

Exchanging InVitro Diagnostics (IVD) Test Orders & Results
Ordering Laboratory Tests for a Patient
Receive Electronic Laboratory Test Results
Support the Transmission of a Laboratory’s Directory of Services to Provider’s Health IT or EHR System

Medical Device Communication to Other Information Systems/Technologies

Transmitting Patient Vital Signs from Medical Devices to Other Information Systems/Technologies

Patient Education Materials

Clinical Information Systems to Request Context-Specific Clinical Knowledge From Online Resources

Patient Identification Management

Patient Demographic Record Matching

Patient Preference/Consent

Recording Patient Preferences for Electronic Consent to Access and/or Share their Health Information with Other Care Providers

Public Health Reporting

Case Reporting to Public Health Agencies
Data Submission for Title X Family Planning Annual Reporting
Electronic Transmission of Reportable Laboratory Results to Public Health Agencies
Exchanging Immunization Data with Immunization Registries
Newborn Screening Results and Birth Defect Reporting to Public Health Agencies
Reporting Antimicrobial Use and Resistance Information to Public Health Agencies
Reporting Birth and Fetal Death to Public Health Agencies
Reporting Cancer Cases to Public Health Agencies
Reporting Death Records to Public Health Agencies
Reporting Syndromic Surveillance to Public Health (Emergency Department, Inpatient, and Urgent Care Settings)
Sending Health Care Survey Information to Public Health Agencies
R-V

Research

Data Collection for Submission to Registries and Reporting Authorities
Pre-population of Research Forms from Electronic Health Records
Registering a Clinical Trial
Submission of Clinical Research Data Contained in EHRs and Other Health IT Systems for General Purpose or Preserving Specific FDA Requirements
Submission of Clinical Research Data to FDA to Support Product Marketing Applications
Submit Adverse Event Report from an Electronic Health Record to Drug Safety Regulators

Segmentation of sensitive information

Data Segmentation of Sensitive Information

Summary care record

Support a Transition of Care or Referral to Another Health Care Provider

Unique Device Identification

Defining a Globally Unique Device Identifier
Representing Unique Implantable Device Identifiers
Transmitting a Unique Device Identifier

Standards and Implementation Specifications for Services and Exchange

"Push” Exchange

An Unsolicited "Push" of Clinical Health Information to a Known Destination and Information System User
An Unsolicited “Push” of Clinical Health Information to a Known Destination Between Systems
Medical Device Communication to Other Information Systems/Technologies
Push Communication of Vital Signs from Medical Devices
Remote Patient Monitoring to Support Chronic Condition Management, Patient Education, and Patient Engagement
Representing Path Traversal Expressions

Clinical Decision Support Services

Providing Patient-Specific Assessments and Recommendations Based on Patient Data for Clinical Decision Support
Retrieval of Contextually Relevant, Patient-Specific Knowledge Resources from Within Clinical Information Systems to Answer Clinical Questions Raised by Patients in the Course of Care

Consumer Access/Exchange of Health Information

Collection and Exchange of Patient Reported Outcomes
Patient Exchanging Secure Messages with Care Providers
Push Patient-Generated Health Data into Integrated EHR
Remote Patient Authorization and Submission of EHR Data for Research
View, Download, and Transmit Data from EHR

Healthcare Directory, Provider Directory

Listing of Providers for Access by Potential Exchange Partners

Image Exchange

Exchanging Images Outside a Specific Health Information Exchange Domain
Exchanging Images Within a Specific Health Information Exchange Domain

Patient Identification Management

Exchanging Patient Identification Management Within a Community

Public Health Exchange

Transport for Immunization Submission and Query/Response

Publish and Subscribe

Publish and Subscribe Message Exchange

Query

Data Element Based Query for Clinical Health Information
Query for Documents Outside a Specific Health Information Exchange Domain
Query for Documents Within a Specific Health Information Exchange Domain

Resource Location

Care Service Discovery Within the US

Administrative Standards and Implementation Specifications

Administrative Transactions - Non-Claims

Administrative Transaction Acknowledgements
Enrollment and Disenrollment in a Health Plan
Health Care Eligibility Benefit Inquiry and Response
Health Care Eligibility Benefit Inquiry and Response for Retail Pharmacy Coverage

Administrative Transactions to Financial Exchanges

Electronic Funds Transfer for Payments to Health Care Providers
Health Care Payment and Remittance Advice
Health Plan Premium Payments for Covered Members

Administrative Transactions to Support Clinical Care

Health Care Attachments to Support Claims, Referrals and Authorizations
Referral Certification and Authorization for Pharmacy Transactions
Referral Certification and Authorization Request and Response for Dental, Professional and Institutional Services

CMS Interoperability Standards for Provider to Provider Communication

Durable Medical Equipment/Home Health Agency Document Request
Durable Medical Equipment/Home Health Agency Order Submission
Durable Medical Equipment/Home Health Agency Signature Request

Health Care Claims and Coordination of Benefits

Health Care Claim Status Request and Response
Health Care Claims or Equivalent Encounter Information for Dental Claims
Health Care Claims or Equivalent Encounter Information for Institutional Claims
Health Care Claims or Equivalent Encounter Information for Professional Claims
Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Claims
Health Care Claims or Equivalent Encounter Information for Retail Pharmacy Supplies and Professional Services

Operating Rules to Support Administrative Transactions

Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV)
Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation (Phase III)
Operating Rules for Prior Authorization (Phase V)
Operating Rules to Support Electronic Prescribing Transactions
Operating Rules to Support Eligibility and Claim Status Transactions (Phase II)
Operating Rules to Support Eligibility Transactions (Phase I)