Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Data Element
Refraction
Description

A refraction test is what the doctor uses to get your eyeglasses prescription. You look at a chart, usually 20 feet away, or in a mirror that makes things look like they’re 20 feet away. You’ll look through a tool called a phoropter. It lets the doctor move lenses of different strengths in front of your eyes. The test also helps your doctor spot presbyopia, hyperopia, myopia, and astigmatism. Source: WebMD Glossary of Eye Tests and Exams LOINC Panel 79895-9
Submitted By: Kerry Goetz / NIH/NEI
Data Element Information
Use Case Description(s)
Use Case Description The National Eye Institute (NEI), part of the National Institutes of Health (NIH), supports the addition of the Ophthalmic terms submitted for inclusion in the United States Core Data for Interoperability (USCDI). NIH issued a guide notice (NOT-OD-20-146) on July 30, 2020 encouraging NIH-supported clinical research programs and researchers to adopt and use the standardized set of data classes, data elements, and associated vocabulary standards specified in the USCDI.
The three items suggested; Intra-ocular pressure, Refraction, and Visual Acuity, are important data points to record patient eye health and treatment, as well quality measurement. Incorporation of these elements will enable NEI researchers to benefit from the opportunities created by the increased availability of clinical data from electronic health record (EHR) systems for research and improved approaches for making data from a single research study useful for other research endeavors. It can complement use of the HL7® Fast Healthcare Interoperability Resources® (FHIR®) standard. The USCDI will enable researchers to leverage structured clinical data for research and enhance the ability to aggregate research data sets and enable discovery.
Estimate the breadth of applicability of the use case(s) for this data element N/A
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC Panel 79895-9 Subjective refraction measurements panel
https://loinc.org/79895-9/
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts N/A
Extent of exchange N/A
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden Minimal
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 1 - Data element is captured, stored, or accessed in at least one production EHR or HIT module.
Criterion #3
Maturity - Current Exchange		 Level 1 - Data element is electronically exchanged between two production EHRs or other HIT modules using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This data element is a specialization of a previously published data element, Clinical Tests (https://www.healthit.gov/isa/taxonomy/term/2456/uscdi-v4), part of USCDI since version 2.

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