The Interoperability Standards Advisory (ISA) process represents the model by which the Office of the National Coordinator for Health Information Technology (ONC) will coordinate the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the United States healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, and research purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA. For historical background on the ISA please review prior ISA publications.

The ISA is frequently updated to include improvements made based on recommendations received from public comments and subject matter expert feedback.  To learn more about major revisions of the ISA, please review recent ISA updates. Registered users may subscribe to change notifications to be alerted by e-mail of all revisions to individual interoperability needs or for ISA-wide changes. Anyone may become a registered user by submitting an account request. Once logged in, look for the blue “change notification” button at the bottom of the interoperability need page, or at the bottom of the home page to be notified of any changes across the ISA. An RSS Feed was also added in 2018, capturing more granular updates made to the ISA.

Scope

Starting with the 2017 ISA, the ISA’s focus expanded to more explicitly include public health and health research interoperability. Thus, its scope includes electronic health information created in the context of treatment, and subsequently used to accomplish a purpose for which interoperability is needed (e.g., a referral to another care provider, public health reporting, or research). Added in late 2017, the ISA now also includes interoperability needs related to Administrative functions within healthcare. These additions were made through coordination with CMS, other administrative healthcare interoperability needs continue to be added. 

The ISA is not exhaustive but it is expected to be incrementally updated to include a broader range of health IT interoperability needs. When more than one standard or implementation specification is listed it is intended to prompt industry dialogue as to whether one standard or implementation specification is necessary or if the industry can efficiently interoperate more than one. It may also reflect the fact that there is an ongoing transition from the use of one standard towards a new version or even a next-generation approach.

As noted in previous ISA publications, a standard listed in one section is not intended to imply that it would always be used or implemented independent of a standard in another section. To the contrary, it will often be necessary to combine the applicable standards from multiple sections to achieve interoperability for a particular clinical health information interoperability need.

It is also important to note that the ISA is designed to inform standards and implementation specification choices for all types of health IT that support interoperability needs, not solely electronic health record (EHR) systems. Furthermore, the ISA is not intended to imply that health IT systems need to support all of the listed standards and implementation specifications. Rather, in the event that a health IT developer or healthcare provider seeks to address a particular interoperability need, the ISA should serve as the first resource consulted to inform the selection of standards and implementation specifications. Additionally, the ISA is designed to inform the “what” that could be used to address an interoperability need in order to assure industry consistency around standards selection and is not mean to explicitly direct “how” the standards and implementation specifications would be implemented to address an interoperability need (e.g., application programming interface or conversion tools).

The ISA is designed to be a coordinated catalog of standards and implementation specifications that can be used by different stakeholders to consistently address a specific interoperability need. However, a listed interoperability need (and its associated standard(s) and implementation specifications(s)) is not meant to universally apply to all stakeholders. Rather, if a listed interoperability need is relevant to a particular clinical specialty, for example, the ISA is designed to provide a consistent foundation from which these stakeholders can agree on applicable technical requirements. Similarly, in cases where a listed interoperability need is not applicable to a given stakeholder group, the ISA in no way compels such stakeholders to consider that interoperability need. 

Please note that the ISA serves as an informational resource for available standards, specifications, profiles, etc that exist to meet the interoperability needs contained within. Stakeholders should ensure and verify that they are adhering to applicable federal, state, and/or local laws or regulations regarding requirements to use a specific standard or specification that may conflict with the information listed in the ISA, as these requirements supersede the ISA. 

Purpose

The Interoperability Standards Advisory is meant to serve at least the following purposes:

1. To provide the industry with a single, public list of standards and implementation specifications that can be used to address specific health information interoperability needs in the United States. Currently, the ISA is focused on interoperability for sharing information between entities and not on intra-organizational uses.  
2. To reflect the results of ongoing dialogue, debate, and consensus among industry stakeholders when more than one standard or implementation specification could be used to address a specific interoperability need, discussion will  take place through the ISA public comments process. The web-version of the ISA improves upon existing processes, making comments more transparent, and allowing for threaded discussions to promote further dialogue.
3. To document known limitations, preconditions, and dependencies as well as provide suggestions for security best practices in the form of security patterns for referenced standards and implementation specifications when they are used to address a specific clinical health IT interoperability need. 

The ISA is designed to provide clarity, consistency, and predictability for the public regarding the standards and implementation specifications that could be used for a given clinical health IT interoperability purpose.

Stakeholders who administer government programs, procurements, and testing or certification programs with clinical health IT interoperability components are encouraged to look first to the ISA in order to more fully inform their goals. In that regard, standards and implementation specifications in the ISA and their associated informative characteristics are also available to help more fully inform policymaking. In this case, a standard or implementation specification’s reference in the ISA may serve as the initial basis for industry or government consideration and action.  While the ISA itself is a non-binding document and meant to be advisory in nature, standards and implementation specifications listed in the ISA may be considered for rulemaking or other Federal requirements. However, those decisions would be made on a case-by-case basis by the administering organization.

This site contains numerous links to other federal agencies and to private organizations. You are subject to these sites’ privacy policies when you access them. HHS is not responsible for Section 508 compliance (accessibility) on other federal or private sites. HHS is not responsible for the contents of any "off-site" web page referenced from this site. 

The ISA is organized and structured into four sections.

• Vocabulary/Code Sets/Terminology Standards and Implementation Specifications (i.e., “semantics”).
• Content/Structure Standards and Implementation Specifications (i.e., “syntax”).
• Standards and Implementation Specifications for Services and Exchange (i.e., the infrastructure components deployed and used to address specific interoperability needs)
• Administrative Standards and Implementation Specifications (i.e., payment, operations and other "non-clinical" interoperability needs)
• Appendices 

Within each section specific “interoperability need” subheadings are listed and followed by tables similar to the one illustrated below.  Each interoperability need may have one or more standards and/or implementation specifications associated with it. Each standard and implementation specification has six informative characteristics attributed to it in order to provide added context.

When known, an “emerging” standard or implementation specification is also listed and is shaded in a lighter color and italicized for additional emphasis. In addition, for vocabulary standards, where there may be one standard used to represent the “observation” or question being asked, and one standard used for the “observation value” or answer these are listed in distinct rows. See Appendix III for educational information about observations and observation values. 

The ISA also includes links within the limitations, dependencies and preconditions to ONC’s Interoperability Proving Ground (IPG) to showcase real-world implementations of standards listed within the ISA. Please note: when accessing links to the IPG, all projects for the selected standard will be listed, including those that may be demonstrating use of the standard for different interoperability needs. In addition, IPG entries are self-reported by stakeholders, so the quality and accuracy of the data may vary across entries.

In the Vocabulary/Terminology section, the vocabulary standards with unspecified code sets or context may be further constrained by a more explicit standard named in a subsequent section. For example, Encounter Diagnoses specifies SNOMED-CT and ICD-10-CM but does not define the context of use. The Standard/Implementation Specification named for the “Interoperability Need: Ordering Labs for a Patient in Content/Structure: Laboratory” further constrains the diagnosis for the patient in the context of a lab order to ICD-9CM or ICD-10CM since the lab order diagnosis is for billing/claims, not clinical diagnostics.

Interoperability need: [Descriptive Text]

Standard Implementation/Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally Required	Cost	Test Tool Availability
Standard	Final	Production		No	Free	No
Standard for observations	Final	Production		Yes	Free	Yes
Standard for observation values	Final	Production		No	Free	Yes
Emerging Standard	Balloted Draft	Pilot		No	Free	No

The following describes the ISA’s six informative characteristics in greater detail.  This detail is meant to better inform stakeholders about the maturity and adoptability of a given standard or implementation specification and provides definition for the terms and symbols used throughout the ISA. Stakeholders should consider all six characteristics together to gain insight into the level of maturity and adoptability of the standards and implementation specifications provided within the ISA.

#1: Standards Process Maturity
This characteristic conveys a standard or implementation specification’s maturity in terms of its stage within a particular organization’s approval/voting process.

• “Final” – when this designation is assigned, the standard or implementation specification is considered “final text” or “normative” by the organization that maintains it. This also includes approved “ANSI Informative” specifications.
• “Balloted Draft” – when this designation is assigned, the standard or implementation specification is considered to be a Draft Standard for Trial Use (DSTU), Standard for Trial Use (STU), or in a “trial implementation” status by the organization that maintains it and has been voted on or approved by its membership as such. This designation does not include standards and implementation guides that are unofficial drafts and early “works in progress”.
• “In Development” – when this designation is assigned, the standard or implementation specification is currently in development. It also includes those that are in the midst of being balloted.  These standards would generally benefit from lessons learned through development and pilots.

#2: Implementation Maturity
This characteristic conveys a standard or implementation specification’s maturity based upon its implementation state. Where available, a link to published maturity assessments based on known published criteria about the standards is also provided. 

• “Production” – when this designation is assigned, the standard or implementation specification is being used in production to meet a health care interoperability need.
• “Pilot” – when this designation is assigned, the standard or implementation specification is being used on a limited scale or only as part of pilots to meet a health care interoperability need.

#3: Adoption Level
This characteristic conveys a standard or implementation specification’s approximate, average adoption level for that specific interoperability need in health care within the United States. The adoption level attempts to consider all implemented technology that would be used to address the identified interoperability need and is not limited to EHRs.  Adoption means that the standard or implementation specification is being used in health IT in the field by end users to address the specific interoperability need. Presently, the adoption levels listed are based on ONC’s analysis of several factors, including, but not limited to: 1) whether and/or how long a standard or implementation specification has been included in regulation for health IT certification (if applicable) or another HHS regulatory or program requirement which is used only as a proxy for industry adoption; 2) feedback from subject matter experts and 3) public comments. 

The adoption level also considers the variety of stakeholders and stakeholder groups that would use the standard and implementation specification to address the specified interoperability need and attempts to display it as such, with the understanding that the designation is a generality or "best guess" and not a pre-defined measured value. Where available, annotated references or links to publicly available documentation known about adoption levels for listed standards are also provided. 

The following scale is used to indicate the approximate, average adoption level among the stakeholders that would use a standard or implementation specification to meet the specified interoperability need:

“Feedback Requested”	Indicates that we do not have a known status for the current level of adoption in health care.
	Indicates low adoption.
	Indicates low-medium adoption.
	Indicates medium adoption.
	Indicates medium-high adoption.
	Indicates high or widespread adoption.

#4: Federally Required
This characteristic (provided as a “Yes” or “No”) conveys whether a standard or implementation specification has been adopted in regulation, referenced as a federal program requirement, or referenced in a federal procurement (i.e., contract or grant) for a particular interoperability need. Where available, a link to the regulation has been provided. Please note this is meant to be provided as a reference only. Entities seeking to comply with federal regulations should look to any and all federal regulations that may apply to ensure adequate compliance. 

#5: Cost
This characteristic conveys whether a fee is involved to purchase, license, or obtain membership for access or use of the recommended standard or implementation specification.

• “$” – when this designation is assigned, it signifies that some type of payment needs to be made in order to obtain the standard or implementation specification. Where known, the estimated cost for access will be provided.
• “Free” – when this designation is assigned, it signifies that the standard or implementation specification can be obtained without cost. This designation applies even if a user account or license agreement is required to obtain the standard at no cost, but is not meant to imply that there are no costs associated with implementation.

#6: Test Tool Availability
This characteristic conveys whether a test tool is available to evaluate health IT’s conformance to the standard or implementation specification for the particular interoperability need. Where available, a link will be provided to the publicly available test tool. 

• “Yes” – When this designation is assigned, it signifies that a test tool is available for a standard or implementation specification and is free to use. Where available, a hyperlink pointing to the test tool will be included.
• “Yes^$”– When this designation is assigned, it signifies that a test tool is available for a standard or implementation specification and has a cost associated with its use. Where available, a hyperlink pointing to the test tool will be included.
• “Yes – Open” – When this designation is assigned, it signifies that a test tool is available for a standard or implementation specification and is available as open source with rights to modify. Where available, a hyperlink pointing to the test tool will be included.
• “No” – When this designation is assigned, it signifies that no test tool is available for a standard or implementation specification.
• “N/A” – When this designation is assigned, it signifies that a test tool for the standard or implementation would be “not applicable.”

Comments on the ISA are accepted year-round, and changes are made to the web version of the ISA frequently throughout the year, based on comments and other changes to the health IT standards environment as ONC becomes aware of them. An annual Review and Comment period also occurs each summer-fall, when a majority of comments are received. See the process timeline below for more details. 

Annual ISA Process Timeline

• January: Current Year Reference Edition is published, web version of ISA is available for ongoing review and comments.
• Winter/Spring/Summer: Changes may be made to the web-version of the ISA throughout the year, while the ISA Reference Edition remains static.
• Late Summer/Early Fall: Annual Review and Comment Period opens for sixty days - site changes are on hold so all reviewers are seeing the same content. 
• Fall: ONC and HHS staff review comments received, make site updates and prepare the following year's Reference Edition for publication by early January. 

How to Comment on the ISA

• An ISA site account is required in order to comment on the ISA.
  • If you have an account already, click the "Login" button at the top right of the ISA. 
  • To create an account, click the "Login" button, then "Create new account" tab above the login window. Account approval is required, and is generally completed within 1 - 24 hours. 
• Once you're authenticated to the ISA site, you can submit comments on most ISA pages - just scroll to the bottom of the relevant page, enter the text of your comment (or provide attachments, if needed) and submit. Your comment will be reviewed by ONC or other HHS subject matter experts, and changes will be considered for publication to the ISA. 
• While comments by topic (posted to individual Interoperability Need pages) are preferred, and allow greater visibility to your comments by other industry stakeholders, consolidated comment letters are also accepted. You may provide these comments on general information pages, and ONC staff will triage them, and assign them to subject matter experts. 

What is the ISA?

The Interoperability Standards Advisory (ISA) process represents the model by which the Office of the National Coordinator for Health Information Technology (ONC) will coordinate the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the United States healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, and research purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. For more information, see the About the ISA page.

Who is the ISA for?

The ISA is meant to serve as a resource for the health IT community. ONC has heard from stakeholders across the health IT industry – public health agencies, standards development organizations, health IT developers, healthcare delivery systems, hospitals, and more – that they are finding a single list of available standards to be a helpful resource for their work to improve healthcare through interoperability.

How often is the ISA updated?

The web version of the ISA is updated on a regular basis by ONC and other HHS staff as changes in the health IT standards environment become apparent or when public comments are received at any point throughout the year. Annually, ONC solicits comments during an official “review and comment period”, typically in the Summer/Fall timeframe, which helps ensure the ISA content is up to date for the annual Reference Edition publication.

How can I comment?

To comment, you’ll need to create an account first. See the Timeline and Comment Process page for more information about account creation, tips for comments, and more.

What is the Reference Edition?

ONC began publishing ISA Reference Editions in 2017 when the ISA transitioned from a static PDF document (with draft/final versions and multiple comment periods annually) to a more interactive web platform. The Reference Edition is meant to provide a stable, non-changing version of the ISA that can be pointed to by industry stakeholders that have that requirement (i.e., for use in contracts, etc). The web version of the ISA is intended to be dynamic and may change a number of times throughout the year as additional comments are received or as ONC becomes aware of changes in the standards listed within the ISA.

How is adoption level calculated?

The adoption level attempts to consider all implemented technology that would be used to address the identified interoperability need, and is not limited to EHRs.  Adoption means that the standard or implementation specification is being used in health IT in the field by end users to address the specific interoperability need. Adoption levels listed are based on ONC’s analysis of several factors, including, but not limited to: 1) whether and/or how long a standard or implementation specification has been included in regulation for health IT certification (if applicable) or another HHS regulatory or program requirement which is used only as a proxy for industry adoption; 2) feedback from subject matter experts and 3) public comments.

The adoption level also considers the variety of stakeholders and stakeholder groups that would use the standard and implementation specification to address the specified interoperability need and attempts to display it as such, with the understanding that the designation is a generality or "best guess" and not a pre-defined measured value. Where available, annotated references or links to publicly available documentation known about adoption levels for listed standards are also provided.

Can I propose an interoperability need that is not listed?

Yes - ONC is always looking for additional interoperability needs that might be valuable for industry stakeholder awareness. You can propose a new interoperability need through the ongoing comment process (account required).

Am I required to use the standards listed in the ISA? 

A standard's listing in the ISA itself does not require its implementation or adoption. The ISA serves as an informational resource for available standards, specifications, profiles, etc that exist to meet the interoperability needs contained within. Stakeholders should ensure and verify that they are adhering to applicable federal, state, and/or local laws, program requirements, or regulations regarding requirements to use a specific standard or specification that may conflict with the information listed in the ISA, as these requirements supersede the ISA.