The Office of the National Coordinator for Health Information Technology (ONC)‘s latest draft of its standards for health interoperability, United States Core Data for Interoperability (USCDI), added two new data classes and 13 new data elements. The fifth version is open for comment until April 15 and will be finalized in July.

Just like previous versions, the current iteration of USCDI aims to help health organizations better standardize data to make it not only interoperable across health care systems and electronic health records (EHRs), but also equitable. Adopting USCDI standards can enhance patient care, increase equity and decrease disparities.  

National Coordinator for Health IT Dr. Micky Tripathi said he sees the public, through this public comment period, playing an important role to informing future versions and helping to achieve fair representation in data standardization across the entire health care ecosystem. 

“We are continuing to build the digital foundation of our health care system with the release of the draft USCDI v5. The new data elements are another step toward improving patient care and patient access, promoting equity, reducing disparities, supporting underserved communities and enabling public health exchange,” said Tripathi.

New Potential Data Classes

New proposed data classes include observations and orders. Observations support multiple activities in a health care session, including diagnoses, test results and screening assessments. Sex parameter for clinical use (SPCU) and advance directive observation are two elements to this new observations data class. 

According to ONC, the SPCU data element would provide sex-specific context to observations, procedures and results. SPCU can also inform clinical decision making, treatment and/or diagnostic tests. Individuals with SPCU attributes of female or male can have: 

• Different reference ranges for a variety of laboratory test results.  
• Different expected findings on diagnostic imaging studies.   
• Different recommended preventive screening recommendations.   
• Different stages of gender-affirming treatment. 

An advance directive observation conveys information about an advance directive document, including its existence, location, content and validity. Communicating and referencing advance directive information, such as a living will or a medical power of attorney, has long been an issue in health care.  

Orders would represent a provider’s intent or directions to initiate care for the patient and addresses other aspects of care including planned procedures, transitions of care, consultations and referrals. This information could be exchanged to communicate intentions with other providers and support care planning and management. 

Other proposed additional data elements include: 

• Emergency department notes and operative notes convey narrative clinical content for coordination of patient care across the continuum and provides critical connections between inpatient and outpatient care settings.   
• Lot number would provide important information for patient care and public health reporting. It’s a required component in the immunization messaging process and is critical for Vaccine Adverse Event Reporting System (VAERS) tracking, as well as in the event of a recall.   
• Author and author role would also offer insight into the source of data, as much health data increasingly comes from multiple sources. Including the source of data can help inform interpretation and validity of the data, leading to better clinical decision-making. Tracing data back to the original author and being able to identify the original source (who or what created the data) supports patient safety.