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- CAP Assessing Data Standard Changes for Electronic Medical Records
On October 23, the Office of the National Coordinator for Health IT (ONC) changed version 4 of the United States Core Data for Interoperability (USCDI) to ensure accuracy of electronic health records. The CAP is assessing these changes and the implications that they have for pathologists, though the changes are not expected to be significant.
The USCDI is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. The ONC changed the vocabulary standards for the Specimen Condition Acceptability and Result Interpretation data elements in the laboratory class as follows:
- For Specimen Condition Acceptability (which we submitted to ONC as Condition and Disposition of Specimens), the ONC is now requiring either SNOMED CT or HL7 Code System SpecimenCondition. Before, SNOMED CT was the only required vocabulary standard.
- For Result Interpretation, the ONC is now requiring either SNOMED CT or HL7 Code System ObservationInterpretation. Before, SNOMED CT was required and HL7 Code System ObservationInterpretation was optional.
The ONC also clarified that the Result Unit of Measure data element was limited to quantitative results. This change is in line with CAP’s advocacy efforts ensuring electronic health record elements are aligned with existing regulatory requirements.