ONC enhances USCDI v4 with 20 new data elements, including allergen information, to drive national health information exchange and boost interoperability. The updates introduce Facility Information and various data elements for allergies, encounter information, goals and preferences, health status assessments, laboratory results, medications, procedures, and vital signs. These improvements aim to improve patient care, support medication reconciliation, and enable better communication and understanding among healthcare providers.
The Office of the National Coordinator for Health Information Technology (ONC) has responded to stakeholder feedback and introduced significant updates to the United States Core Data for Interoperability Version 4 (USCDI v4) to promote better interoperability, particularly regarding allergen information.
USCDI v4 serves as a pivotal health IT standard, forming the foundation for national health information exchange (HIE).
Notable enhancements in USCDI v4 include the establishment of a new data class called “Facility Information,” comprising three data elements: Facility Identifier, Facility Type, and Facility Name. This class provides crucial details about the physical locations where medical services have been or can be provided, enabling improved care planning, emergency response, and identification of services available across multiple facilities.
Moreover, the existing USCDI data classes underwent several changes to accommodate valuable insights and improve patient care:
1. ALLERGIES AND INTOLERANCES: The new data element, Substance (Non-Medication), has been added to represent common allergens such as latex, peanuts, and eggs, filling the need for standardized data on non-medication substances alongside medication-related information.
2. ENCOUNTER INFORMATION: The new data element, Encounter Identifier, facilitates linking data related to an encounter, such as diagnoses and prescribed medications, streamlining information exchange for better patient care.
3. GOALS AND PREFERENCES: Understanding patients’ goals and preferences is essential for person-centered care. To enable this, ONC added two data elements, Treatment Intervention Preference and Care Experience Preference, to the “Goals and Preferences” data class.
4. HEALTH STATUS ASSESSMENTS: The Health Status Assessments data class has been expanded with three new data elements: Alcohol Use, Substance Use, and Physical Activity, enhancing the exchange and use of structured assessment data.
5. LABORATORY: To support public health reporting and offer patients and providers more detailed laboratory data interpretations, six new data elements have been introduced to the Laboratory data class, including Result Unit of Measure, Result Reference Range, and Result Interpretation, among others.
6. MEDICATIONS: Acknowledging the importance of patient medication information exchange, ONC has included two new data elements in the Medications data class: Medication Instructions and Medication Adherence. The latter, which includes patient-reported data, fosters greater patient engagement and facilitates medication reconciliation.
7. PROCEDURES: Ensuring the capture and sharing of procedure occurrences, ONC added Performance Time to the Procedures data class.
8. VITAL SIGNS: The Vital Signs data class has been supplemented with the inclusion of Average Blood Pressure, a significant independent risk factor in various diseases and health conditions.
To ensure the accurate interpretation of Average Blood Pressure values, ONC emphasized the potential need for information about the period, number of readings, and specific protocols used.
These updates to USCDI v4 signify a major step forward in promoting interoperability and advancing the exchange of health information, ultimately contributing to more effective and patient-centric healthcare practices.
