United States Core Data for Interoperability (USCDI)
The United States Core Data for Interoperability (USCDI) is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. Review the USCDI Fact Sheet to learn more.
A USCDI Data Class is an aggregation of Data Elements by a common theme or use case.
A USCDI Data Element is a piece of data defined in USCDI for access, exchange or use of electronic health information.
USCDI ONC New Data Element & Class (ONDEC) Submission System
USCDI V1
Please reference the USCDI version 1 document to the left for applicable standards versions associated with USCDI v1.
Harmful or undesired physiological responses associated with exposure to a substance.
Health professional’s conclusions and working assumptions that will guide treatment of the patient.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
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- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
Desired state to be achieved by a patient.
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.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data used to categorize individuals for identification, records matching, and other purposes.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Representing a patient’s smoking behavior.
Unique identifier(s) for a patient's implantable device(s).
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
USCDI V2
The USCDI v2 contains data classes and elements from USCDI v1 and new data classes and elements submitted through the ONDEC system. Please reference the USCDI Version 2 document to the left for applicable vocabulary standards versions associated with USCDI v2 and to the ONC Standards Bulletin 21-3 for more information about the process to develop USCDI v2 and future versions.
Harmful or undesired physiological responses associated with exposure to a substance.
Health professional’s conclusions and working assumptions that will guide treatment of the patient.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
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- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Desired state to be achieved by a patient.
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.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data used to categorize individuals for identification, records matching, and other purposes.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Representing a patient’s smoking behavior.
Unique identifier(s) for a patient's implantable device(s).
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
USCDI V3
USCDI v3 contains data classes and elements from USCDI v2 and new data classes and elements submitted through the ONDEC system. Please reference the USCDI Version 3 document to the left for applicable vocabulary standards versions associated with USCDI v3 and to the ONC Standards Bulletin 22-2 for more information about the process to develop USCDI v3 and future versions.
Harmful or undesired physiological responses associated with exposure to a substance.
Health professional’s conclusions and working assumptions that will guide treatment of the patient.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
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- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Desired state to be achieved by a patient.
Data related to an individual’s insurance coverage for health care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data used to categorize individuals for identification, records matching, and other purposes.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Unique identifier(s) for a patient's implantable device(s).
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
USCDI V4
USCDI v4 added 20 data elements and one data class to USCDI v3. Please reference the USCDI v4 standard document and the ONC Standards Bulletin 23-2 for details. To review the prioritization criteria ONC used to select the USCDI v4 data elements, refer to the ONC Standards Bulletin 22-2.
Harmful or undesired physiological responses associated with exposure to a substance.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
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- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Physical place of available services or resources.
Desired state to be achieved by a person or a person’s elections to guide care.
Data related to an individual’s insurance coverage for health care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data used to categorize individuals for identification, records matching, and other purposes.
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
USCDI V5
USCDI v5 was published on July 16, 2024, and includes 16 new data elements and two new data classes. Please read the USCDI v5 standard document and the ONC Standards Bulletin 24-2 for details.
Harmful or undesired physiological responses associated with exposure to a substance.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
-
- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Physical place of available services or resources.
Desired state to be achieved by a person or a person’s elections to guide care.
Data related to an individual’s insurance coverage for health care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Findings or other clinical data collected about a patient during care.
Provider-authored request for the delivery of patient care services.
Data used to categorize individuals for identification, records matching, and other purposes.
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
Draft USCDI V6
ASTP/ONC published Draft USCDI v6 on January 14, 2025, and proposes to add 6 new data elements. Please read the Draft USCDI v6 standard document and the ASTP Standards Bulletin 25-1 for details. ASTP/ONC is accepting comments here through May 12, 2025, at 11:59 PM ET.
Harmful or undesired physiological responses associated with exposure to a substance.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
-
- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Physical place of available services or resources.
Desired state to be achieved by a person or a person’s elections to guide care.
Data related to an individual’s insurance coverage for health care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Findings or other clinical data collected about a patient during care.
Provider-authored request for the delivery of patient care services.
Data used to categorize individuals for identification, records matching, and other purposes.
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
- Represented by a terminology standard or SDO-balloted technical specification or implementation guide.
- Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
- Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
- Use cases apply to most care settings or specialties.
Level 2
Harmful or undesired physiological responses associated with exposure to a substance.
Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity.
Tests that result in visual images requiring interpretation by a credentialed professional.
Physical place of available services or resources.
Data related to an individual’s insurance coverage for health care.
Record of vaccine administration.
An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Provider-authored request for the delivery of patient care services.
Data used to categorize individuals for identification, records matching, and other purposes.
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
- Represented by a terminology standard or SDO-balloted technical specification or implementation guide.
- Data element is captured, stored, or accessed in at least one production EHR or HIT module.
- Data element is electronically exchanged between two production EHRs or other HIT modules using available interoperability standards.
- Use cases apply to several care settings or specialties.
Level 1
Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity.
Narrative patient data relevant to the context identified by note types.
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- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
Physical place of available services or resources.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Analysis of clinical specimens to obtain information about the health of a patient.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data used to categorize individuals for identification, records matching, and other purposes.
The metadata, or extra information about data, regarding who created the data and when it was created.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
- Not represented by a terminology standard or SDO-balloted technical specification or implementation guide.
- Data element is captured, stored, or accessed in limited settings such as a pilot or proof of concept demonstration.
- Data element is electronically exchanged in limited environments, such as connectathons or pilots.
- Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Level 0
Harmful or undesired physiological responses associated with exposure to a substance.
Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity.
Information about a person who participates or is expected to participate in the care of a patient.
Narrative patient data relevant to the context identified by note types.
-
- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
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.
Tests that result in visual images requiring interpretation by a credentialed professional.
Information related to interactions between healthcare providers and a patient.
Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.
Desired state to be achieved by a patient.
Desired state to be achieved by a person or a person’s elections to guide care.
Data related to an individual’s insurance coverage for health care.
Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.
Record of vaccine administration.
Analysis of clinical specimens to obtain information about the health of a patient.
An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose.
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Findings or other clinical data collected about a patient during care.
Provider-authored request for the delivery of patient care services.
Data used to categorize individuals for identification, records matching, and other purposes.
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
Condition, diagnosis, or reason for seeking medical attention.
Activity performed for or on a patient as part of the provision of care.
The metadata, or extra information about data, regarding who created the data and when it was created.
Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.
The USCDI ONC New Data Element and Class (ONDEC) Submission System supports a predictable, transparent, and collaborative process, allowing health IT stakeholders to submit new data elements and classes for future versions of USCDI. Click here for more information and to submit new data elements.
The USCDI standard will follow the Standards Version Advancement Process described in the Cures rule to allow health IT developers to update their systems to newer version of USCDI and provide these updates to their customers.
Comment
Submitted by MRMabry on
RadNet's Comments on Draft USCDI Version 2
RadNet appreciates the opportunity to comment on the draft USCDI version 2. Specifically, we support: (1) the proposed new “Diagnostic Imaging” data class which would consist of two new data elements, “Diagnostic Imaging Report” and “Diagnostic Imaging Order,” plus the existing data element for “Diagnostic Imaging Narrative” (included under Clinical Notes in USCDI version 1) subject to clarification and (2) the use of the LOINC® (Logical Observation Identifiers Names and Codes) as their respective standard.
Submitted by shannon.vogel@… on
USCDI Draft v2 Comments from Texas Medical Association
Please find attached comments on USCDI Draft Version 2 from the Texas Medical Association.
Submitted by ScottFujimoto-CDPH on
California Department of Public Health comments on USCDI V2
Good Morning,
The California Department of Public Health recommends adding the following data elements for the Patient Profile in exchange between EHRs:
Patient Demographics: Expand to cover Social Determinants of Health
- Number of Dependents
- Sexual Orientation
- Gender Identity
- Sex Assigned At Birth
- Gender of Sex Partners
- Preferred Language
- Country of Birth
- Last report of homelessness
- Last report of incarceration
- Last report of food insecurity
- Current occupation/occupation history
- Insurance Status
Smoking Status: Smoking, tobacco use, alcohol use, and illicit drug use are found in multiple areas of the record ( e.g. Smoking Status, Substance Use, and Social History). Recommend streamlining all substance use items in the same part of the record, preferably the Substance Use section.
- Simply recording smoking status is insufficient given the evolving types of nicotine products and dual use and should be replaced with response to the question, “In the PAST 12 MONTHS, how often have you used any tobacco product (for example, cigarettes, vapes, cigars, pipes, or smokeless tobacco)?” Values of frequency are to be identified as appropriate.
- Follow-up questions on types and frequency of tobacco products used (e.g. cigarettes, vapes, cigars, pipes, smokeless tobacco)
- Specific response on marijuana use similar to the tobacco question: "In the PAST 12 MONTHS, how often have you used any marijuana product (for example, smoked, vaped, dabbed, or ingested)?"
- Follow-up questions on types and frequency of marijuana products used
- Last report of active alcohol use
- Last report of recreational opioid use
- Last report of methamphetamine use
Vital Signs: Expand to include social/mental assessment
- Last reported blood pressure (both systolic and diastolic if possible)
- Last PHQ-9 >10 consistent with moderate to severe depression
- Last BMI >30 consistent with medical obesity
- Pregnancy Status (if pregnant, estimated date of delivery)
- CDPH recommends that providers screen patients for signs of loneliness as per the three-item loneliness scale in the journal article "Social Isolation and Loneliness: The New Geriatric Giants: Approach for Primary Care" at Can Fam Physician. 2020 Mar;66(3):176-182. PMID: 32165464.
- For patients older than 65 years of age: Last asked about cognitive impairment/Last memory assessment (e.g., Mini-Cog© S. Borson) administered.
- Results of Adverse Childhood Experiences screening questions (i.e., number and type of ACEs)
- Referrals made based on ACEs screening results/score
- Resources provided based on ACEs screening results/score
- Was patient referred to child welfare services as a result of the screening results/score
- Number and type of Positive Childhood Experiences (PCEs)
Diagnostic Imaging
- Order Date (found in Orders or Imaging section)
- Report Date (if available, would be found in one of these sections: Orders, Results, Imaging)
Laboratory
- Date Specimen Collected
- Last lab consistent with COVID infection
- Last lab consistent with latent TB infection
- Last lab consistent with active TB infection
- Interferon-gamma release assay result
- Tuberculin skin test: Date placed (may be in Laboratory or Immunization section)
- Tuberculin skin test: Date read
- Tuberculin skin test result
- Last lab consistent with Chlamydia trachomatis, Gonorrhea, or Syphilis infection
- Last serology/viral load for Hepatitis B, Hepatitis C, and HIV infection
- Last reported Hemoglobin A1c
- Last reported total cholesterol
Immunizations
- Immunization Record (including, but not limited to, COVID or influenza)
Medications
- Reason medication stopped
Assessment and Plan of Treatment
- For adults who report current tobacco use: Referral to state tobacco quit line (e.g. California Smokers' Helpline)
- For adults with chronic condition (i.e., obesity, diabetes, hypertension, hypercholesterolemia), last referral to lifestyle change program (e.g., Diabetes Self-Management Education, Chronic Disease Self-Management Program, Self-Measured Blood Pressure Monitoring, National Diabetes Prevention Program)
Submitted by Robert Hussey on
Comments from Wolters Kluwer on USCDI v. 2
Attached are comments from Wolters Kluwer on the proposed version 2 of the United States Core Data for Interoperability. Thanks for the opportunity to share our views.
Submitted by Solarf3050 on
Draft USCDI Version 2 Comments
Attached are Health Level Seven (HL7) International’s comments on ONC’s Draft United States Core Data for Interoperability (USCDI) Version 2 and related data classes standards and elements. We look forward to continuing this discussion and offer our assistance to ONC.
Submitted by Riki Merrick APHL on
General suggestions
- We suggest to include all data elements are marked as required/SHALL/must support in both HL7® FHIR® US Core and HL7® CDA® C-CDA for the document types referenced in the 2015 Certification Edition Cures Update as well as in the V2 IGs cited in any meaningful use regulation in the USCDI v2.
- Vocabulary standards
- We suggest to rename the term “applicable standards” in USCDI to “vocabulary standards” or “terminology standards” as they only intent to reference vocabulary/terminology standards, not syntax or transport standards, which are defined elsewhere. The term “applicable standards” is just too broad and too misleading as to what standards are being referenced from within USCDI vs. outside of USCDI on how to communicate/access/exchange USCDI data.
- We suggest that the applicable standards, i.e., vocabulary standards, referenced in USCDI are updated to reflect the most current version available at time of publishing USCDI v2
Submitted by SamanthaBurch on
American Hospital Association Comments on USCDI Draft V2
General Comments
The American Hospitals Association (AHA) appreciates the open, transparent process ONC has established to solicit new data classes and elements for potential inclusion in future versions of the US Core Data for Interoperability (USCDI) and gather feedback from a broad range of stakeholders as well as the federal Health IT Advisory Committee (HITAC). Hospitals and health systems see the value in structured data elements to support a variety of important use cases including care coordination, public health, quality reporting, value-based care, health equity, and more.
Overall, the AHA is supportive of the USCDI draft version 2 as presented by ONC. The limited expansion from version 1, consistent with ONC’s guiding principles of minimal burden and complementing existing USCDI data elements, represents an appropriate bridge to future versions, while filling important gaps in data elements that exist today. This approach recognizes the continued limitations on resources on the part of hospitals and health systems to undertake new IT projects, such as voluntary upgrades to new versions of the USCDI, while continuing to focus on COVID response, vaccine distribution, data reporting, telehealth, new interoperability regulatory requirements and other key priorities.
As health care providers work with their EHR vendors to implement version 1 of the USCDI, we encourage ONC to engage closely with the field to identify and address implementation challenges as they arise. We further encourage ONC to ensure there are clear definitions for all data elements and all associated standards are identified. This will assist in supporting a common understanding of each data element across health care organizations.
Timing of Future Versions. While the AHA appreciates the process set forth by ONC to annually accept submissions of additional data classes and elements from stakeholders, we question whether the approach of finalizing a new USCDI version every year allows enough time to fully evaluate, define, implement and improve on each version. With the USCDI version 1 now adopted in regulation and linked to the information blocking requirements in the Cures Act Final Rule through October 6, 2022, we request that ONC provide clarity to the field on its regulatory approach to adoption of future USCDI versions.
Level 2 Data Classes and Elements
SDOH. The AHA supports the addition of data classes and elements to future versions of the USCDI that will enable standardized capture of social determinants of health (SDOH) and other equity data. EHRs can be an important tool to support collection of the data necessary to gain key insights at the patient and population health levels and build data-driven interventions. We look forward to submitting additional specific comments in response to the ONC’s information collection request on SDOH data elements.
Submitted by ddoneski on
NASL Comments on USCDI V2
The National Association for the Support of Long Term Care (NASL) is a national trade association representing the providers of ancillary care and services and products to the long term and post-acute care (LTPAC) sector. NASL members include rehabilitation therapy companies; providers of clinical laboratory services and portable x-ray; suppliers of complex medical equipment and other specialized supplies; and health information technology (health IT) companies that develop and distribute full clinical electronic medical records (EMRs), billing and point-of-care health IT systems and other software solutions serving the majority of LTPAC providers (i.e., assisted living, home health, inpatient rehabilitation facilities, long term care hospitals and skilled nursing facilities). NASL also is a founding member of the Long Term & Post-Acute Care Health IT Collaborative, which formed in 2005 to advance health IT issues by encouraging coordination among provider organizations, policymakers, vendors, payers and other stakeholders.
NASL appreciates the opportunity to share our comments regarding the Draft US Code for Data Interoperability Version 2.
Submitted by achu626 on
Comments Regarding Draft USCDI v2
Radix Health appreciates the opportunity to comment on the USCDI v2 draft. Radix Health specializes in enabling medical and hospital groups to reduce delays in care, maximize provider utilization, and ensure the right match between patient and provider. With this in mind, we offer our suggestions for improvements that affect the ability for systems to exchange data critical to patient access and scheduling.
Encounters
In its simplest form, electronic medical records help provide the who, what, when, and where for patients. Patients demographic records are often the foundation of healthcare data, and is the who. Whereas medications, problems, treatments, and diagnostics or results are often descriptive of the patient, this is the what. Encounter data allows you to describe the when and where.
As the standard currently stands, Radix recommends additional data elements to fully round out the encounter to better capture data that is pertinent to time and location. More specifically, appointment information is crucial to providing visibility into a patient's history, it can act as time markers with important context.
Encounters currently detail the type, time, place, and could benefit from a provider(s) component (level 2), status (level 1), as well as a note element (comment). These additional details would provide additional detail into a patient's history that could further assist in their care and health information portability.
Appointments
While many systems have a correlation between an encounter and an appointment, these are often times different concepts. Appointments can capture data up to the point of care, while most of it may be financial and administrative, they may also capture clinical data in more simple systems, like for therapy appointments that may come from lightweight systems that are not full featured EHRs.
In this case, an expansion of the Encounters Data to account for appointment elements like appointment type, appointment status, and appointment notes would help round out the data needs for patient access and scheduling needs. Appointment type, which may be unique from Encounter Type, would ultimately allow lighter weight systems to contribute meaningful data to standard, rather than adjusting it to the Encounter data components that may not be as accurate. Appointment status would help convey the differences in appointments (or encounters) that exist in a system. Appointment notes, like encounter notes, add extra detail to appointments that may be difficult to capture elsewhere.
Scheduling
One of the biggest challenges of healthcare is provider accessibility. This is most often due to the complicated nature for which many providers are scheduled. By making standards for how provider availability and accessibility can be accessed, we open up the opportunity for innovators to make patient access more simple. Making providers more accessible will increase health outcomes simply by reducing the friction for patients to see doctors.
Summary
A person's healthcare is ultimately controlled by the individual. Should they seek care, enabling the individual to more easily and more quickly access the care they need when and how they want it is critical to enabling better outcomes. Much of that care begins when a patient schedules an appointment. Making the process of scheduling appointments, or coordinating appointments across places of care, improve the chances of the patient following through with their care plan.
Submitted by kamodeo on
American Academy of Ophthalmology Comments on USCDIv2
Please find comments from the American Academy of Ophthalmology in the attached document.
AAO Comments on USCDI_Final.pdf