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ISA Content
ISA Document Table of Contents
Vocabulary/Code Set/Terminology
Content/Structure
Services/Exchange
Administrative
Appendices
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
COVID-19 Novel Coronavirus Pandemic
COVID-19 Novel Coronavirus Pandemic
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
Health Concerns
Representing Patient Health Concerns
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
Representing Work Information
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
Public Health Emergency Preparedness and Response
Representing Healthcare Personnel Status
Representing Hospital/Facility Beds Utilization
Representing Laboratory Operations (Population Laboratory Surveillance)
Representing Population-Level Morbidity and Mortality
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
Sending a Notification of a Patient’s Encounter to a Record Locator Service
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 Within and Between Communities
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
Eligibility and Benefits Operating Rules for Standard Transactions
Operating Rules for Benefit Enrollment
Operating Rules for Claims
Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation
Operating Rules for Premium Payments
Operating Rules for Prior Authorization and Referrals
Operating Rules to Support Claim Status Transactions
Operating Rules to Support Electronic Prescribing Transactions
Appendix I – Sources of Security Standards and Security Patterns
Appendix II - Models and Profiles
Appendix III - Educational and Informational Resources
Understanding Emerging API-Based Standards
Understanding Observations and Observation Values
Appendix IV - State and Local Public Health Readiness for Interoperability
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