Data Element

Additional Information

Values/Results
Description
Documented findings of the analysis of a tested specimen. Includes both structured and unstructured (narrative) components.

Comment

Rename the element to Result Value; clarify its definition/use

This element should be called Result Value (to differentiate it from the performed test, which some also refer to as "result") (in v2 reported in OBX-5, in C-CDA and FHIR in observation.value). While the definition indicates this captures structured and unstructured data it is missing all the detail around how to address the different formats:
  • unstructured = narrative results use formated text, are human readable, but not easily usable for computers and harder to use in data comparison
  • structured results fall into several categories and should be represented as follows:
    • For qualitative tests:
      • Coded to SNOMED CT drawn from organism hierarchy for organism names; drwan from qualifier hierachy for presence/absence findings and other ordinal results; drawn from clinical findings for pathology, microscopy, microbiology
      • include the original text the coding was based on, if different from the description of the code
    • For quantitative tests:
      • include (in a separate field) the units of measure – coded to UCUM) - this should NOT be sent as a string in a single result field
      • use a structured numeric datatype to allow support for ranges, ratios and smaller than/greater than statements 
This is a subtype of the proposed element Observation Value (https://www.healthit.gov/isa/taxonomy/term/1401/level-2), so if that is added clarification between when to use which would be needed. This is a CLIA required element.

Addition to my comment above

The level 2 element https://www.healthit.gov/isa/taxonomy/term/2446/level-2 supports the renaming - these two elements need to be reconciled.

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