As discussed in Module 1, the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

Health care terminologies are the backbone of healthcare information exchange standards, for example, as part of the United States Core Data for Interoperability (USCDI).

ASTP/ONC established the USCDI to help promote and facilitate healthcare information exchange. USCDI is a standardized set of health data classes or elements, like patient names and medication lists, for nationwide, interoperable health information exchange. The USCDI is one of several baseline criteria for systems that participate in the ONC Health IT Certification Program and is used as part of the CMS Promoting Interoperability program (previously Meaningful Use, as mentioned in Module 1).

Through a transparent and collaborative process with health IT stakeholders, ASTP/ONC reviews and designates data standards and terminologies to be used for the USCDI data elements. It is possible for a data element to have more than one applicable standard (e.g., for Medications, both RxNorm and NDC are allowed) and there are some data elements that have yet to have a standard identified.

For example, using USCDI V4 for the Data Element – Body Weight, under the Data Class – Vital Signs, both Logical Observation Identifiers Names and Codes (LOINC) and Unified Code of Units for Measure (UCUM) are designated as the applicable standards for use. LOINC is used to report the weight observation and UCUM is the unit of measure (along with a numeric result). This means that certified health IT systems in the U.S. must use the LOINC standard when exchanging health information related to reporting weight observations and UCUM as the unit of measure for the observation result.

Here is the full list of USCDI V4 Data Classes and Data Elements.

Activity

Explore several of the data classes and elements featured under ASTP/ONC’s USCDI V4 (such as Allergies and Intolerances – Substance Medication, Vital Signs – Systolic Blood Pressure, Procedures – Reason for Referral) and note the "Applicable Vocabulary Standard(s)."

Many of the terminologies we will cover, including SNOMED CT, RxNorm, LOINC, ICD-10, and CPT, are designated for use by USCDI in one or more data elements.