• SNOMED CT U.S. Edition may not be sufficient to differentiate between an allergy or adverse reaction, or the level of severity.
• For use of SNOMED CT U.S. Edition, codes should generally be chosen from the clinical finding axis.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The starter value set Common Environmental Substances for Allergy and Intolerance documentation (2.16.840.1.113762.1.4.1186.4) provides a limited set of SNOMED CT codes for substances commonly associated with allergic reactions, but it is not exhaustive. Many other substances with codes in the SNOMED CT Substance hierarchy may be associated with allergic reactions.
• The Allergic disposition (disorder) hierarchy provides an alternative representation for allergies that can be used on a problem list, medical history, or encounter diagnosis.

• The starter value set Common dietary substances for allergy and intolerance documentation (2.16.840.1.113762.1.4.1186.3) provides a limited set of SNOMED CT codes for substances commonly associated with allergic reactions, but is not exhaustive. Many other substances with codes in the SNOMED CT Substance hierarchy may be associated with allergic reactions.
• The Propensity to adverse reactions to food (disorder) hierarchy provides an alternative representation for allergies that can be used on a problem list, medical history, or encounter diagnosis.

• SNOMED CT U.S. Edition should be used to represent an allergy or intolerance at the medication class level.

• MED-RT is managed by the US Veterans Health Administration and may be used to represent an allergy or intolerance at the medical class level. 

   

• ISBT 128 is the global standard for the terminology, identification, coding and labeling of medical products of human origin (including blood, cell, tissue, milk, and organ products).

LOINC:

• A Consultation note is generated as part of a request from a clinician for an opinion or advice from another clinician.

• A Discharge Summary note is a synopsis of a patient’s admission and course in a hospital or post-acute care setting.

• A History & Physical note documents the current and past conditions of the patient.

• A Progress Note represents a patient's interval status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

IHE:

• See also Integrating the Healthcare Enterprise (IHE) IT Infrastructure White Paper: Enabling Document Sharing Health Information Exchange Using IHE Profiles.

• Clinical Tests is a USCDI data class representing non-imaging and non-laboratory tests performed on a patient that results in structured or unstructured (narrative) findings specific to the patient, such as electrocardiogram (ECG), visual acuity exam, macular exam, or graded exercise testing (GXT), to facilitate the diagnosis and management of conditions.

• Feedback requested.

• The PACIO Project is developing FHIR use cases for the exchange of functional status and cognitive status information between healthcare settings.
  • Cognitive Status Implementation Guide
•  The CMS Data Element Library provides the ability to download assessment data elements, including functional status, and associated health IT standards from the:
  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  • Long-Term Care Hospital Continuity Assessment Record Set (LCDS)
  • Resident Assessment Instrument - Minimum Data Set (MDS)
  • Outcome and Assessment Information Set (OASIS)
  • Hospice Item Set (HIS) 

• The following artifacts provide additional guidance on adopting codes, terminologies and coding guidance:
  • CDC Official FY2022 Coding and Reporting Guidelines for ICD-10-CM
  • Logica (FHIR v4.0) Implementation Guide: COVID-19
  • SNOMED CT U.S. Edition Coding for COVID-19 Data
  • Guidance for mapping to SARS-CoV-2 LOINC terms
  • LOINC In Vitro Diagnostic (LIVD) Test Code Mapping for SARS-CoV-2 Tests, Specimens and Results (CDC/FDA)
  • COVID-19 Lab Data Reporting Implementation Specifications includes HL7 Field and HL7 V2 Message guidance
  • NCPDP® Emergency Preparedness Guidance document – This document provides guidance to the pharmacy industry for resources available during the pandemic.
• The FHIR profiles in the Logica IG: COVID-19 contains FHIR profiles representing COVID-19 related data elements to support patient care, billing, research, or public reporting. The goal is to create consistent and reusable data and FHIR profiles for different COVID-19 implementation guides.
• The HL7 Situational Awareness for Novel Epidemic Response (SANER) Implementation Guide enables transmission of high- level situational awareness information from inpatient facilities to centralized data repositories to support the treatment of novel influenza-like illness.
• The COVID-19 Interoperability Alliance stewards more than 600 value sets on behalf of collaborators that include SNOMED International, Regenstrief, Logica Health, the National Association of Community Health Centers, MITRE and more. These value sets support data aggregation, analytics, population cohort identification, clinical trials, and medical research.
• CDC and FDA maintain mapping of all current US approved SARS-CoV-2 invitro diagnostic lab and their corresponding specimen types and results.
• CMS Press Release on HCPCS Codes for Coronavirus Lab Testing
• CARES Act Section 18115 require laboratories to report results of SARS-CoV2 or COVID-19 testing to the Secretary of HHS in the form and manner outlined in this memo "COVID-19 Pandemic Response, Laboratory Data Reporting: CARES Act Section 18115 June 4, 2020"
• CMS COVID-19 Vaccine Policies & Guidance
• CDC COVID-19 Vaccine Data Systems

• Telecom Data Elements:
  • Phone Number, Phone Number Type - For §170.315 (b)(1) Transitions of care and §170.315 (b)(4) Common Clinical Data Set summary record – create, patient matching data must represent phone number (home, business, cell) in accordance with the above standards. All phone numbers must be included when multiple phone numbers are present.
  • Email Address - Per ITU–T E.123 (02/2001) above, an electronic mail address, if present, should be printed in the SMTP style below the
    telephone number information, and denoted by the label "E-mail" or some easily recognized variation such as "email," or the equivalent in the appropriate language.

• Nutrition Care Process Terminology (NCPT) and is owned, maintained, and distributed by the Academy of Nutrition and Dietetics to support standardization of the Nutrition Care Process. Many of the terms in the NCPT have been mapped to SNOMED and/or LOINC.

• Refer to the Gravity Project for details on identifying food insecurities.

• Refer to Allergies and Intolerances-Representing Patient Allergies and Intolerances; Food Substances for detail on identifying allergies and intolerances related to food substances.

• The National Emergency Medical Services Information System (NEMSIS) administered by the National Highway Traffic Safety Administration’s Office of Emergency Medical Services provides a universal standard for the collection and transmission of emergency medical services (EMS) operations and patient care data. Using NEMSIS-compliant electronic patient care record (ePCR) software products, data are collected by EMS practitioners at the point of care and includes information on the EMS system response, scene characteristics, patient demographics, patient condition, medical treatment provided, transport decision, patient and incident disposition and EMS system times (e.g., response time, scene time, transport time).  NEMSIS includes the National EMS Database which accepts EMS data voluntarily submitted by U.S. States and Territories. Using NEMSIS-compliant ePCR software products, local EMS systems collect a national set of data elements for submission to the National EMS Database through their respective state. Local EMS systems and states have the option to collect additional NEMSIS data elements to meet local and state needs. The NEMSIS standard follows a 5-year revisioning cycle.  The two most recent NEMSIS standard versions (V3.4.0 and 3.5.0 as of January 2021) are available for ePCR software product compliance testing and submission to the National EMS Database.  NEMSIS standard version 3.5.0 was released in 2019.  NEMSIS Version 3 standards (i.e., V3.4.0, and V3.5.0) include integration of several HL7® data standards, such as LOINC®, RxNorm, and ICD-10-CM.  NEMSIS standard versions V3.4.0 and V3.5.0 are HL7 compliant and ANSI accredited.
• NEMSIS uses Extensible Markup Language (XML) to move data. States and software companies create products that are used to send and receive EMS data in the proper XML format from agencies to states, then on to the National EMS Database. More information about NEMSIS is available at https://nemsis.org/technical-resources/.
• Mapping and translation resources are available for mapping or translating older versions of the NEMSIS dataset to newer versions of the dataset.

• Feedback requested.

• SNODENT is owned, maintained and distributed by the American Dental Association (ADA®). The SNODENT code set is available under license at no cost for non-commercial use. The license agreement terms also permit licensees to use SNODENT in the development of non-commercial, academic, scholarly articles and presentations for publication.

• Use of SNOMED CT U.S. Edition codes should generally be chosen from three axes: Clinical finding, Situation with explicit context, and Event.
• The use of these standards may be further constrained by other standards and implementation specifications found elsewhere in the ISA.
• Systems should be able to process (or at minimum display) data coded using the older ICD-9-CM standard, as this legacy content still exists and may be used for analysis/decision support/quality measurement needs, where retroactive analysis is often required, but ICD-9 should not be collected for new entries. NLM has maps from ICD-9-CM diagnosis and procedure codes to SNOMED CT U.S. Edition to facilitate code translation and integration with newly collected SNOMED CT U.S. Edition data:
  • ICD-9-CM Diagnostic Codes to SNOMED CT U.S. Edition
  • ICD-9-CM Procedure Codes to SNOMED CT U.S. Edition
• A mapping from SNOMED CT U.S. Edition to ICD-10-CM is available from the National Library of Medicine to support semi-automated generation of ICD-10-CM codes from clinical data encoded in SNOMED CT U.S. Edition for reimbursement and statistical purposes.
• HIPAA mandates the use of ICD-10 for pharmacy claims using NCPDP® standards, while SNOMED CT U.S. Edition is optional for this use. 

• The Monarch Initiative maintains the Human Phenotype Ontology (HPO) of medically relevant phenotypes, disease-phenotype annotations, and algorithms. 
• The Human Genome Organization (HUGO) Gene Nomenclature Committee maintains the HUGO Gene Nomenclature and approves gene names and symbols (short-form abbreviation) for each known human gene.
• The Human Genome Variation Society (HGVS) Variant Nomenclature Committee (HVNC), under the auspices of the HUGO Gene Nomenclature committee maintains the HGVS Nomenclature.
• The National Library of Medicine National Center for Biotechnology Information (NLM NCBI) maintains the Reference Sequence Database - a comprehensive, integrated, non-redundant, well-annotated set of reference sequences including genomic DNA, transcripts, and proteins. 
• NLM NCBI maintains dbVAR, a database of human genomic structural variation. 
• Implementation information for Family Member History exchange can be found in Representing Family Health History for Clinical Genomics
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Resources for this interoperability need include:
  • Social Security Association’s Disability Determination Process
  • American College of Occupational and Environmental Medicine additional resources on Functional Status/Disability.
  • American Medical Association's “Guides to the Evaluation of Permanent Impairment, Sixth Edition”
  • The International Classification of Functioning, Disability and Health (ICF) is a World Health Organization (WHO) framework to describe and measure health and disability at both individual and population levels.
•  The CMS Data Element Library also provides the ability to download assessment data elements, including functional status, and  associated health IT standards from the:
  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  • Long-Term Care Hospital Continuity Assessment Record and Evaluation Data Set (LCDS)
  • Resident Assessment Instrument - Minimum Data Set (MDS)
  • Outcome and Assessment Information Set (OASIS)
  • Functional Assessment Standardized Items (FASI) 
• The PACIO Project is developing FHIR use cases for the exchange of functional status and cognitive status information between healthcare settings.
  • PACIO’s Functional Status Implementation Guide (IG) has been officially published as Standard for Trial Use specifications by HL7. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 
• The interoperability need is directed to cover people's functional activities at the level of the individual, including activity limitations, the ability to participate in or be involved in all areas of life, and any participation restrictions as a person or member of society.

• The CMS Data Element Library also provides the ability to download assessment data elements, including various assessments of patient goals, and associated health IT standards such as LOINC and SNOMED CT U.S. Edition from the:
  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  • Long-Term Care Hospital Continuity Assessment Record and Evaluation Data Set (LCDS)
  • Resident Assessment Instrument - Minimum Data Set (MDS)
  • Outcome and Assessment Information Set (OASIS)
  • Functional Assessment Standardized Items (FASI) 

• NPPES permits non-billable care team members to apply for an NPI number to capture the concept of ‘person’.
• The National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set identifies health care provider groupings, classifications, and areas of specialization. It does include other providers than health care providers, which is defined by federal regulations.
• The adoption of NPI for pharmacy/prescribing may be higher than for general use, however, not all prescribers (e.g., veterinarians, etc) are able to obtain an NPI. 

• Feedback requested.

• This value set is derived from the HL7 Vocabulary code system "RoleCode".

• A Health Concern is a health-related matter that is of interest, importance or worry to someone, who may be the patient, patient's family, or patient's health care provider. Health concerns are derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). Health concerns can be medical, surgical, nursing, allied health or patient-reported concerns.

• Radiological Society of North America (Radlex) and Regenstrief Institute (LOINC) have harmonized terms for radiology procedures.
• Current Procedural Terminology (CPT) is a code set, maintained by the American Medical Association (AMA) used to bill outpatient and office procedures.

LOINC:

• An Imaging Narrative contains a consulting specialist's interpretation of image data.

General considerations:

• The list above includes any vocabulary used to record immunizations in any health IT system including IIS, pharmacy, billing, etc. 
• NDC has been used by pharmacies to report historical doses for billing purposes, so it is included here in that context.  
• The CDC's National Center for Immunization and Respiratory Diseases (NCIRD) developed and maintains the CVX and MVX code systems, and developed and maintains the NDC vaccine tables based on information published by the FDA.
• RxNorm is an acceptable alternative code set for use at the local level.
• RxNorm is utilized for immunization analytics.
• RxNorm is not utilized for reporting of previous dispensing but can be employed to specify the drug being prescribed. 

For Immunization Information System (IIS) consideration:

• The CDC's National Center for Immunization and Respiratory Diseases (NCIRD) developed and maintains the CVX and MVX code systems, and developed and maintains the NDC vaccine tables based on information published by the FDA.
• CVX codes are designed to represent administered and historical immunizations and will not contain manufacturer-specific information.
• If an MVX code is paired with a CVX (vaccine administered) code, the specific trade named vaccine may be indicated providing further specificity as to the vaccines administered.
• There is a potential issue with use of the National Drug Code regarding which code to use when there are multiple active ingredients in a single package or multiple separate ingredients that need to be mixed together. CDC has published guidance on NDC Unit of Use and Unit of Sale; it can be found at: https://www.cdc.gov/vaccines/programs/iis/2d-barcodes/downloads/guidance-documenting-ndc.pdf.
• The lot number is used in conjunction with the NDC when reporting immunizations to IIS. There is no standard codification for lot numbers.
• The IIS community does not utilize RxNorm as a code set and thus it may have limitations for interoperability across systems.

• Correct handling and interpretation of laboratory test values requires information about the test instance, including the result value, the units, the reference range. 
• Units of measure for quantitative result values may be represented using UCUM, see Representing Units of Measure. 
• Qualitative result values may be represented using LOINC answer lists or SNOMED CT U.S. Edition codes.
• Future uses of laboratory test results may include “real world evidence” collection for final regulatory approval, test harmonization status, and performance monitoring of specific commercial products. These tasks will require results to include device IDs, test kit IDs, kit versions, reagent lots, and calibrator lots. 

• LOINC codes identify the clinical concept of the test ordered, which enables consistent interpretation across systems and organizations regardless of a laboratory’s local codes. The LOINC code to represent the order may not be the same LOINC code as the one for the performed test when the performed test code is more specific in one of the LOINC parts (e.g., method or system) or when the order combines multiple tests into a panel.
• CPT-PLA codes represent advanced diagnostic laboratory tests (ADLTs) and clinical diagnostic laboratory tests (CDLTs) that are cleared and approved by the Food and Drug Administration (FDA). CPT-PLA codes provide relevant clinical information about the test ordered, including information on analytical services required for the analysis (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, hybridization, and detection).

• Laboratory test performed is used by a laboratory to report test results.
• LOINC codes represent laboratory tests in general and do not represent a manufacturer's specific laboratory test. 
• For more information about representing laboratory tests as a procedure, see the Representing Medical Procedures page. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Feedback requested.

• RxNorm is often used for the exchange of information; however, it may not be available for export and import by end users.
• RxNorm is a terminology built on and derived from other terminologies which represent various elements within RxNorm, including dose form and units of measure. RxNorm reflects and preserves the meanings, drug names, attributes, and relationships from its sources.  
• The use of NDC in conjunction with RxNorm can help minimize gaps in representing medications, including compounded products, over -the-counter medications, and herbals.
• Note: All over-the-counter, botanicals, and herbal supplements also need to be considered in the management of medications and the conditions for which they are used. Not all of these are well-represented using the standards indicated above.
• Immunizations are not considered medications for this interoperability need.
• Medication Route and other components of Medication is often represented using SNOMED CT, US Edition in some interoperability specifications such as C-CDA.

• Concepts for observation values from SNOMED CT U.S. Edition should generally be chosen from two axes: Clinical finding and Situation with explicit context.
• When representing validated scales, LOINC should be used for the question and LOINC answers (LA Codes) should be used for the answers.
• Question/Answer (name/value) pairs are a valuable representation of assessments, but best practices indicate the full question with answer should be included in communication. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• According to the Journal of Nursing Education  nursing interventions can be defined as "any task that a nurse does to or for the patient" or "something that directly leads to a patient outcome."
• Coded interventions may be linked as related/dependent concepts to observations and assessments, as appropriate.
• The Procedure axis of SNOMED CT U.S. Edition is the terminology used for Nursing Interventions.

• Reference to Standard Nursing Terminologies
• Other ANA-recognized terminologies should be mapped to LOINC for comparison across health systems and/or transmission.
• Use LOINC if the outcome is a measurement.
• Use SNOMED CT U.S. Edition if the outcome is an observed assessment that a patient state has improved.  In addition, when the outcome is recorded as an assertion (e.g., normotensive, afebrile, etc.) the terminology to be used is SNOMED CT U.S. Edition. 
• Additional information about terminology standards related to nursing is available in an ASTP-funded report: Standard  Nursing Terminologies (A Landscape Analysis)
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The use of SNOMED CT U.S. Edition for this interoperability need, codes should generally be chosen from two axes: Clinical finding and Situation with explicit context.
• Local and other ANA-recognized terminologies should be converted to SNOMED CT U.S. Edition for comparison across health systems and/or transmission.

• The use of SNOMED CT U.S. Edition for this interoperability need, codes should generally be chosen from three axes: Clinical finding, Situation with explicit context, and Event.
• SNOMED CT U.S. Edition supports the combination of codes (post-coordination) to generate new meaning. Codes from other axes can be used in post-coordination. The need to pick multiple codes may be seen as a disadvantage. This can be avoided if post-coordination is limited to the backend, exposing a single code for users to pick.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• RFC 5646 encompasses ISO 639-1, ISO 639-2, ISO 639-3 and other standards related to identifying preferred language.

• When patient is currently pregnant, additional data fields should be collected, including: date of pregnancy status, estimated delivery date or gestational age. See applicable value sets and Recommendations from Collaboration of the Health IT Policy and Health IT Standards Committees' Public Health Task Force (Excel File Download, 31KB) for more details.
• There are ongoing deliberations within CDC and other organizations to identify the best location to capture pregnancy status in provider workflows..
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee.

• Feedback requested.

• ICD-10-PCS is primarily a billing code used only in inpatient settings.
• CPT and HCPCS are codes used to report procedures and services in outpatient procedures.
• ICD-10-PCS is named in the 2015 Edition certification rules as an optional code set for procedures.
• SNOMED CT U.S. Edition procedure codes can be used to describe treatment in any clinical setting and is not tied to billing but can be cross-mapped to corresponding ICD-10-PCS and CPT/HCPCS codes.

LOINC:

• A Procedure Note records the indications for a non-operative procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
• A Pathology Report Narrative contains a consulting specialist's interpretation of the pathology report.

• Feedback requested.

• Data Elements:
  • Author Time Stamp-indicates the time the information was recorded
  • Author Organization-the organization the author is associated with at the time they interacted with the data.

• The CDC, Center of Emergency Preparedness and Response, Situational Awareness branch, collaborating with the National Information Exchange Model (NIEM), developed -a population-level public health emergency preparedness and response information exchange requirements, which includes a minimum data set, and standardized vocabulary. Data comes directly from hospital and long-term care facility databases, not directly linked to the EHR.
• The Healthcare personnel status section of the minimum data set provides vocabulary for a population-level reporting healthcare personnel morbidity and mortality during an emergency event.

Feedback requested

• The CDC Developed Code Systems includes Race & Ethnicity Code System – CDCREC 1.2 and Race & Ethnicity Code System – CDCREC 1.0 which expands upon and can be rolled up to the OMB standards may help to further define race and ethnicity for this interoperability need as it allows for multiple races and ethnicities to be chosen for the same patient.
• The CDC Race and Ethnicity Code Set Version 1.2 is minor update to Version 1.0 and is the current version for CDC reporting requirements.
• The high-level race/ethnicity categories in the OMB Standard may be suitable for some statistical or epidemiologic or public health reporting purposes but may not be adequate for other uses such as in the pursuit of precision medicine and enhancing therapy or clinical decisions.
• LOINC® provides observation codes for use in the observation/observation value pattern for communicating race and ethnicity. LOINC is used to capture race and/or ethnicity in multiple coded panels; some of these align with the OMB race and ethnicity Category codes (e.g., 72826-1 69490-1).
• On March 28, 2024, OMB finalized revisions to Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (SPD 15). The 2024 revisions to SPD 15 are effective as of its publication date, and Federal agencies must comply with these updates as soon as possible, and, in any case, no later than March 28, 2029.

• Any patient receiving healthcare in the United States may have some tribal affiliation, including patients from any other country or locale in the world. Some patients are members of a federally recognized tribe, some are members of a state recognized tribe, some are members of tribes in the process of seeking federal or state recognition, and some may self-report an affiliation or enrollment in more than one tribe or community inside or outside the U.S. Only tribes define and determine tribal enrollment. Federal, state, and local entities do not have the ability to verify tribal enrollment. Use of tribal affiliation allows for the collection of what tribe(s) an individual patient identifies with, without impeding on tribal sovereignty in any way.
• The HL7 TribalEntityUS code system is modeled after the Bureau of Indian Affairs (BIA) list of federally recognized tribes, state recognized tribes, and other entities in Alaska and the contiguous U.S. To aid in identifying Tribal name changes, the Tribe's previously listed, former name, or also known as (aka) is included in parentheses after the correct current Tribal name on the https://www.bia.gov/as-ia/ofa website.

• The adoption and federally required levels for using CDISC SDTM for QRS, Medical Devices and Pharmacogenomics purposes vary.
• Medical Dictionary for Regulatory Activities (MedDRA) is a standardized medical terminology developed by ICH,  to facilitate sharing of regulatory information internationally for medical products used by humans. It is used for registration, documentation and safety monitoring of medical products both before and after a product has been authorized for use. 

• The HL7 Gender Harmony Project provides guidance on how to exchange clinical sex and gender affirming information using HL7 models. 
• For more information about observations and observation values, see Appendix II for an informational resource developed by the Health IT Standards Committee. 

• Sex Assigned at Birth may be exchanged as a unique data element or as a kind of Recorded Sex or Gender as described in the HL7 Gender Harmony implementation guide. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies LOINC codes for exchanging alcohol use observations. This criterion was not changed in HTI-1. 
• The Alcohol Use Disorder Identification Test - Consumption [AUDIT-C] contains a subset of the World Health Organization’s 10-question AUDIT alcohol screening. Both are used to identify patients who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). 
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. 
• Units of measure for quantitative result values must be represented using UCUM, see Representing Units of Measure. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies LOINC codes for exchanging depression observations. This criterion was not changed in HTI-1. 
• The Patient Health Questionnaire 2 item (PHQ-2) is a two-question screening tool for symptoms of depression in the past two weeks.  It consists of the first two questions of the PHQ-9. 
• The full Patient Health Questionnaire 9 item (PHQ-9) incorporates DSM-IV depression criteria with other major depressive symptoms into a brief self-report instrument commonly used for screening and diagnosis, as well as selecting and monitoring treatment.
• The HL7® Post Acute Care Interoperability (PACIO) project provides additional information about the depression screening panels.
• The Beck Depression Inventory Fast Screen (BDI FS) is a shorter version of the Beck Depression Inventory II (BDI II). The BDI FS contains seven items from the BDI II and is used to evaluate depression symptoms in alignment with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for depression. [PMID:19010075]
• Units of measure for quantitative result values must be represented using UCUM, see Representing Units of Measure. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies a LOINC code for exchanging  information about the highest grade or level of school, or highest degree a person has completed. This criterion was not changed in HTI-1. 
• Educational attainment is defined by the HL7® Gravity Project as failing to meet academic criteria for high school diploma or equivalent.
• The scope of the HL7 Gravity Project Educational Attainment domain is more broad than the certification criterion and includes information about related conditions and interventions. 
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for SDOH exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Elder abuse is defined by the HL7 Gravity Project as an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult and can be in the form of physical abuse, psychological abuse, sexual abuse, financial abuse, and neglect by someone in a caregiving role. 
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH interventions.
• Implementation information for Elder Abuse exchange can be found in Structure and Exchange of Social Determinants of Health Information.

• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

   

• Employment status is defined by the HL7 Gravity Project as whether a person is employed or not employed, is available for work or is looking for employment.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Employment Status exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies a LOINC code for exchanging  information about a person's financial resource strain. This criterion was not changed in HTI-1. 
• Financial insecurity is defined by the HL7 Gravity Project as a state of being wherein a person has difficulty fully meeting current and/or ongoing financial obligations and/or does not feel secure in their financial future.
• The scope of the HL7 Gravity Project Financial Insecurity domain is more broad than the certification criterion and includes information about related conditions and interventions.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Financial Insecurity exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Food insecurity is defined by the HL7 Gravity Project as uncertain, limited, or unstable access to food that is: adequate in quantity and in nutritional quality; culturally acceptable; safe and acquired in socially acceptable ways.  
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT and HCPCS Level II are used for SDOH procedures and interventions.
• Implementation information for Food Insecurity exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

Health insurance coverage is defined by the HL7 Gravity Project as documentation of presence and type of insurance. 

LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  

SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.

ICD-10-CM is used for SDOH diagnoses.

CPT is used for SDOH procedures and interventions.

Implementation information for Health Insurance Coverage exchange can be found in Structure and Exchange of Social Determinants of Health Information.

For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Homelessness is defined by the HL7 Gravity Project in two ways, sheltered and unsheltered. 
  • Sheltered homelessness is currently living in a shelter, motel, temporary or transitional living situation, scattered-site housing, or not having a consistent place to sleep at night. 
  • Unsheltered homelessness is residing in a place not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, on the street.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Homelessness exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Housing instability is defined by the HL7 Gravity Project as currently consistently housed but experiencing any of the following circumstances in the last 12 months: behind on rent or mortgage, 3 or more relocations, housing cost burden, homelessness, or risk of eviction.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, diagnoses, procedures and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT and HCPCS Level II are used for SDOH procedures and interventions.
• Implementation information for Housing Instability exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Inadequate housing is defined by the HL7 Gravity Project as having housing that does not meet habitability standards. 
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, diagnoses, procedures and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT and HCPCS Level II are used for SDOH procedures and interventions.
• Implementation information for Inadequate Housing exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies LOINC codes for exchanging  information about exposure to violence (intimate partner violence). This criterion was not changed in HTI-1. 
• Intimate partner violence is defined by the HL7 Gravity Project as physical violence, sexual violence,  or psychological harm by a current or former partner or spouse. Often including a pattern of methods and tactics to gain and maintain power and control over the other person. 
• The scope of the HL7 Gravity Project Intimate Partner Violence domain is more broad than the certification criterion and includes information about related conditions and interventions.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Units of measure for quantitative result values must be represented using UCUM, see Representing Units of Measure. 
• Implementation information for Intimate Partner Violence exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Material hardship is defined by the HL7 Gravity Project as the lack of specific socially perceived basic physical necessities.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Material Hardship exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Medical cost burden is defined by the HL7 Gravity Project as a measure of financial pressure resulting from health spending stemming from inadequate resources to meet medical cost needs.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Medical Cost Burden exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies LOINC codes for exchanging  information about a person's physical activity. This criterion was not changed in HTI-1. 
• SAMHSA adopted a two-question screen aligned with the LOINC codes referenced in HTI-1.  
• The HL7® FHIR® Physical Activity Implementation Guide contains value sets to represent physical activity questions, answers, interventions and measurements. 
• Units of measure for quantitative result values must be represented using UCUM, see Representing Units of Measure. 
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Feedback requested.

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies LOINC codes for exchanging  information about social connection and isolation. This criterion was not changed in HTI-1. 
• Social connection is defined by the HL7 Gravity Project as encompassing the structural, functional, and quality aspects of how individuals connect to each other, and contains three components:
  • Social Isolation: Objectively being alone, having few relationships, or infrequent social contact,
  • Loneliness: Subjectively feeling alone. The discrepancy between one’s desired level of connection and one’s actual level, and
  • Social Support: Actual or perceived availability of resources (e.g., informational, tangible, emotional) from others. Four types of social supportive behaviors: emotional, instrumental, informational, and appraisal. 
• The scope of the HL7 Gravity Project Social Connection domain is more broad than the certification criterion and includes information about related conditions and interventions.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Units of measure for quantitative result values must be represented using UCUM, see Representing Units of Measure. 
• Implementation information for Social Connection exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• Social Determinants of Health (SDOH) conditions and diagnoses are SDOH-related problems, concerns, conditions, or diagnoses, often determined by screening assessments of an SDOH-related risk. 
• The HL7 Gravity Project defined value sets to represent SDOH Problems and Health Concerns.
  • SNOMED CT U.S. Edition is used for SDOH conditions.
  • ICD-10-CM is used for SDOH diagnoses.
• Implementation information for SDOH conditions and diagnoses exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• A white paper developed by National Council for Prescription Drug Programs (NCPDP), Collecting and Exchanging Social Determinants of Health Data in the Pharmacy, provides guidance on the use of ICD-10-CM and SNOMED CT US Edition codes within the NCPDP SCRIPT and Telecommunication Standards, as well as the Pharmacist eCare Plan.

• Social Determinants of Health (SDOH) Goals are the desired future state for an identified SDOH-related concern, condition, or diagnosis.
• The HL7 Gravity Project established and maintains value sets representing SDOH Goals.
  • SNOMED CT U.S. Edition is used to represent SDOH Goals. 
• Implementation information for SDOH goals exchange can be found in Structure and Exchange of Social Determinants of Health Information.

• Social Determinants of Health (SDOH) Interventions are actions or services to address an identified SDOH-related concern, condition, or diagnosis.
• The HL7 Gravity Project established and maintains current value sets which represent SDOH Interventions.
• Implementation information for SDOH interventions exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• SNOMED CT U.S. Edition, CPT and HCPCS Level II are used to represent procedures and interventions.

• Social Determinants of Health (SDOH) Screening Assessments are questionnaire-based, structured evaluations for an SDOH-related risk. (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool).
• The HL7 Gravity Project established and maintains current value sets which represent SDOH Screening Assessments.  
• SNOMED CT U.S. Edition is used to represent answers to SDOH assessment questions.
• LOINC is used to represent SDOH assessment tools and the questions within. 
• Implementation information for SDOH Assessment exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee. 

• The optional 2015 Edition Cures Act Social, psychological, and behavioral data criterion (170.315(a)(15)) specifies a LOINC code for exchanging information about the level of stress a person is experiencing. This criterion was not changed in HTI-1. 
• Stress is defined by the HL7 Gravity Project as occurring when a person perceives the demands of environmental stimuli to be greater than their ability to meet, mitigate, or alter those demands.
• The scope of the HL7 Gravity Project Stress domain is more broad than the certification criterion and includes information about related conditions and interventions.
• LOINC is used for Social Determinants of Health (SDOH) observations (assessment instrument panels, questions, and answers.)  
• SNOMED CT U.S. Edition is used for SDOH observations, conditions, goals, and interventions.
• ICD-10-CM is used for SDOH diagnoses.
• CPT is used for SDOH procedures and interventions.
• Implementation information for Stress exchange can be found in Structure and Exchange of Social Determinants of Health Information.
• For more information about observations and observation values, see Appendix III for an informational resource developed by the Health IT Standards Committee.