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

Applicable Vocabulary Standard(s)

Clinical Test

The name of the non-imaging or non-laboratory test performed on a patient.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
Clinical Test Result/Report

Interpreted results of clinical tests that may include study performed, reason performed, findings, and impressions. Includes both structured and unstructured (narrative) components.

Data Element

Applicable Vocabulary Standard(s)

Clinical Test

Non-imaging or non-laboratory test.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
Clinical Test Result/Report

Findings of clinical tests.

Data Element

Applicable Vocabulary Standard(s)

Clinical Test

Non-imaging or non-laboratory test.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.72
Clinical Test Result/Report

Findings of clinical tests.

Data Element

Applicable Vocabulary Standard(s)

Clinical Test

Non-imaging or non-laboratory test.

Examples include but are not limited to electrocardiogram (ECG), visual acuity exam, macular exam, or graded exercise testing (GXT).

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
Clinical Test Result/Report

Findings of clinical tests.

Data Element

Applicable Vocabulary Standard(s)

Clinical Test

Non-imaging or non-laboratory test.

Examples include but are not limited to electrocardiogram (ECG), visual acuity exam, macular exam, and graded exercise testing (GXT).

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.77
Clinical Test Result/Report

Findings of clinical tests.

Data Element

Applicable Vocabulary Standard(s)

Clinical Test

Non-imaging or non-laboratory test.

Examples include but are not limited to electrocardiogram (ECG), visual acuity exam, macular exam, and graded exercise testing (GXT).

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.80
Clinical Test Result/Report

Findings of clinical tests.

Comment

Comment on Laboratory Data (CCD–FHIR Project & Sequoia& Oracle )

 

Currently, the lack of clear guidance makes laboratory result matching imprecise and reconciliation a laborious process. Catalog maintenance is an ongoing burden. There is no consistent guidance on laboratory orderables & specimens and other parameters —including biomarkers—and their associated results. Keeping orderable/result mapping catalogs synchronized between LIS, EHRs, and device/manufacturer reference data is highly resource-intensive.

Publicly sharing LIS and manufacturer instrument catalogs—including the preferred LOINC and SNOMED CT code values—would be beneficial for providers, potentially reducing duplicate test orders, lowering interpretation errors, and speeding alignment. However, most catalogs remain proprietary. Complicating matters further, a single orderable can trigger additional reflex tests or downstream orderables, without any supporting workflow guides.  In addition, LIS systems lack federal support for maintaining and exchanging catalog formats.

It is essential to enable LIS vendors, manufacturers, and providers to publish and share their coded catalogs in a standardized way. This would help EHR systems interpret the vast LOINC vocabulary, recognizing that not all codes are used in practice. Developing standard code value sets—potentially at state and federal levels—would further improve consistency and interoperability.

Recommendation: ONC should work with HL7, Sequoia Project, LIS vendors, manufacturers, and providers and EHRs to establish guidance and infrastructure for sharing laboratory orderable and result catalogs, including standardized value sets for LOINC and SNOMED CT, to support more accurate laboratory result matching and reconciliation under USCDI.

Related data suggestion

While we are considering the addition of Ophthalmic Data I would suggest adding the date that a dilated diabetic eye exam was performed.  This is a very important data element for diabetes disease management for individuals and populations as well as for quality reporting.

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