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<title>Health Data Standards and Terminologies: A Tutorial</title>
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data-bs-toggle="dropdown" data-bs-auto-close="false"
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aria-haspopup="true"
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aria-expanded="false">
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1: Functions and Types of Health Information Standards
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-1">
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<li><a class="dropdown-item" href="01-100.html" aria-current="true">Intro</a></li>
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<li><a class="dropdown-item" href="01-200.html">The Electronic Health Record (EHR)</a></li>
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<li><a class="dropdown-item" href="01-300.html">Interoperability</a></li>
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<li><a class="dropdown-item" href="01-400.html">Health Data Standards</a></li>
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<li><a class="dropdown-item" href="01-500.html">Module 1 Knowledge Check</a></li>
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-2" aria-haspopup="true" aria-expanded="true">
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2: Terminology Standards and Tools
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-2">
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<li><a class="dropdown-item" href="02-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="02-200.html">What are Terminology Standards?</a></li>
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<li><a class="dropdown-item" href="02-300.html">Characteristics of a Standardized Terminology</a></li>
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<li><a class="dropdown-item active" href="02-400.html">ASTP/ONC and USCDI</a></li>
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<li><a class="dropdown-item dropdown-toggle" href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-Term" aria-haspopup="true" aria-expanded="false">Overview of Terminologies</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-Term">
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<li><a class="dropdown-item" href="02-500.html">Terminology Examples</a></li>
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<li><a class="dropdown-item" href="02-510.html">SNOMED CT</a></li>
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<li><a class="dropdown-item" href="02-520.html">RxNorm</a></li>
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<li><a class="dropdown-item" href="02-530.html">LOINC</a></li>
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<li><a class="dropdown-item" href="02-540.html">ICD</a></li>
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<li><a class="dropdown-item" href="02-550.html">CPT</a></li>
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<li><a class="dropdown-item" href="02-560.html">MeSH</a></li>
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<li><a class="dropdown-item" href="02-570.html">UCUM</a></li>
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</ul>
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</li>
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<li><a class="dropdown-item dropdown-toggle" href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-Tool" aria-haspopup="true" aria-expanded="false">Terminology Tools and Resources</a>
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<li><a class="dropdown-item" href="02-600.html">NLM Examples</a></li>
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<li><a class="dropdown-item" href="02-610.html">UMLS</a></li>
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<li><a class="dropdown-item" href="02-620.html">RxNav</a></li>
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<li><a class="dropdown-item" href="02-630.html">DailyMed</a></li>
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<li><a class="dropdown-item" href="02-640.html">VSAC</a></li>
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<li><a class="dropdown-item" href="02-650.html">AccessGUDID</a></li>
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<li><a class="dropdown-item" href="02-660.html">MedlinePlus Connect</a></li>
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<li><a class="dropdown-item" href="02-670.html">NIH Common Data Element Repository (CDE-R)</a></li>
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</ul>
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</li>
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<li><a class="dropdown-item" href="02-700.html">Module 2 Knowledge Check</a></li>
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</ul>
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<li class="nav-item dropdown">
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-3" aria-haspopup="true" aria-expanded="false">
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3: Exchange Standards
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</a>
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<li><a class="dropdown-item" href="03-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="03-400.html">Version 3 (V3)</a></li>
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<li><a class="dropdown-item" href="03-500.html">Clinical Document Architecture (CDA)</a></li>
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<li><a class="dropdown-item" href="03-600.html">Fast Healthcare Interoperability Resources (FHIR)</a></li>
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<li><a class="dropdown-item" href="03-700.html">Module 3 Knowledge Check</a></li>
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</ul>
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<li class="nav-item dropdown">
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<a class="nav-link dropdown-toggle"
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href="#" role="button" data-bs-toggle="dropdown" data-bs-auto-close="false" id="navbarDropdown-4" aria-haspopup="true" aria-expanded="false">
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4: Working Together - Revisiting Organizational Interoperability
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown-3">
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<li><a class="dropdown-item" href="04-100.html">Intro</a></li>
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<li><a class="dropdown-item" href="04-200.html">Implementation Guides</a></li>
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<li><a class="dropdown-item" href="04-300.html">Health Information Exchange (HIE)</a></li>
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<li><a class="dropdown-item" href="04-400.html">Government Programs</a></li>
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<header class="bg-secondary p-3 truncate shadow" style="border-bottom: 1px solid #eee;">
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<strong>Health Data Standards and Terminologies</strong>
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<small class="text-muted">A Tutorial</small>
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<a href="https://learn.nlm.nih.gov/" id="anch_30" target="_blank">Learning Resources</a>
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<a class="nav-link" href="index.html">Course Home</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-1">1: Functions and Types of Health Information Standards</a>
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<div id="collapse-item-1" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="01-100.html">Intro</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="01-200.html">The Electronic Health Record (EHR)</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="01-300.html">Interoperability</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="01-400.html">Health Data Standards</a>
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<li class="nav-item">
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<a class="nav-link" href="01-500.html">Module 1 Knowledge Check</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-2">2: Terminology Standards and Tools</a>
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<li class="nav-item">
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<a class="nav-link" href="02-100.html">Intro</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-200.html">What are Terminology Standards?</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-300.html">Characteristics of a Standardized Terminology</a>
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</li>
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<li class="nav-item">
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<a class="nav-link active" href="02-400.html">ASTP/ONC and USCDI</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="#collapse-item-Term" data-bs-toggle="collapse">Overview of Terminologies</a>
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<div id="collapse-item-Term" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="02-500.html">Terminology Examples</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-510.html">SNOMED CT</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-520.html">RxNorm</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-530.html">LOINC</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-540.html">ICD</a>
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||
</li>
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||
<li class="nav-item">
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<a class="nav-link" href="02-550.html">CPT</a>
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||
</li>
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<li class="nav-item">
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<a class="nav-link" href="02-560.html">MeSH</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-570.html">UCUM</a>
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</li>
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</ul>
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</div>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="#collapse-item-Tool" data-bs-toggle="collapse">Terminology Tools and Resources</a>
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<div id="collapse-item-Tool" class="collapse">
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<ul class="nav flex-column ps-3">
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<li class="nav-item">
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<a class="nav-link" href="02-600.html">NLM Examples</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="02-610.html">UMLS</a>
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</li>
|
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<li class="nav-item">
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||
<a class="nav-link" href="02-620.html">RxNav</a>
|
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</li>
|
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<li class="nav-item">
|
||
<a class="nav-link" href="02-630.html">DailyMed</a>
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||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="02-640.html">VSAC</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="02-650.html">AccessGUDID</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="02-660.html">MedlinePlus Connect</a>
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||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="02-670.html">NIH Common Data Element Repository (CDE-R)</a>
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||
</li>
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</ul>
|
||
</div>
|
||
|
||
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||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="02-700.html">Module 2 Knowledge Check</a>
|
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</li>
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</ul>
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</div>
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</li>
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|
||
|
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<li class="nav-item">
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<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-3">3: Exchange Standards</a>
|
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<div id="collapse-item-3" class="collapse">
|
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<ul class="nav flex-column ps-3">
|
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<li class="nav-item">
|
||
<a class="nav-link" href="03-100.html">Intro</a>
|
||
</li>
|
||
<li class="nav-item">
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<a class="nav-link" href="03-200.html">HL7 International</a>
|
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</li>
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<li class="nav-item">
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<a class="nav-link" href="03-300.html">Version 2 (V2)</a>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="03-400.html">Version 3 (V3)</a>
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</li>
|
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<li class="nav-item">
|
||
<a class="nav-link" href="03-500.html">Clinical Document Architecture (CDA)</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="03-600.html">Fast Healthcare Interoperability Resources (FHIR)</a>
|
||
</li>
|
||
<li class="nav-item">
|
||
<a class="nav-link" href="03-700.html">Module 3 Knowledge Check</a>
|
||
</li>
|
||
</ul>
|
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</div>
|
||
</li>
|
||
|
||
<li class="nav-item">
|
||
<a class="nav-link" data-bs-toggle="collapse" href="#collapse-item-4">4: Working Together - Revisiting Organizational Interoperability</a>
|
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<div id="collapse-item-4" class="collapse">
|
||
<ul class="nav flex-column ps-3">
|
||
<li class="nav-item">
|
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<a class="nav-link" href="04-100.html">Intro</a>
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</li>
|
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<li class="nav-item">
|
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<a class="nav-link" href="04-200.html">Implementation Guides</a>
|
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</li>
|
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<li class="nav-item">
|
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<a class="nav-link" href="04-300.html">Health Information Exchange (HIE)</a>
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</li>
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<li class="nav-item">
|
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<a class="nav-link" href="04-400.html">Government Programs</a>
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</li>
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</ul>
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</div>
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</li>
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<li class="nav-item">
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<a class="nav-link" href="05-000.html">Closing</a>
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<li style="height: auto; line-height: 0;"><hr></li>
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<li class="nav-item">
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<a class="nav-link" href="06-000.html">Additional Resources</a>
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<a class="nav-link" data-bs-toggle="modal" data-bs-target="#navModal">How to Navigate This Course</a>
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There are a variety of ways you can navigate this course. You can:</p>
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<li>Use a combination of the above methods to explore the course contents.</li>
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<h2>2: Terminology Standards and Tools
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</h2>
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<hr>
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<h3>ASTP/ONC and USCDI</h3>
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<br>
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<p>As discussed in Module 1, the <a href="https://www.healthit.gov/" title="Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC)" target="_blank">Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC)</a> 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.</p>
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<p>Health care terminologies are the backbone of healthcare information exchange standards, for example, as part of the <a href="https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi" title="United States Core Data for Interoperability (USCDI)" target="_blank">United States Core Data for Interoperability (USCDI)</a>.</p>
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<p>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 <a href="https://www.healthit.gov/topic/certification-ehrs/certification-health-it" title="ONC Health IT Certification Program" target="_blank">ONC Health IT Certification Program</a> and is used as part of the CMS Promoting Interoperability program (previously Meaningful Use, as mentioned in Module 1).</p>
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<div class="alert alert-info shadow" role="alert">
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<p><strong>The USCDI is comprised of:</strong></p>
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<ul>
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<li><strong>Data elements</strong> - the most granular level at which a piece of data is represented in the USCDI for exchange.</li>
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<li><strong>Data classes</strong> - a grouping of related data elements.</li>
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</ul>
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</div>
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<p>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. </p>
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<p>For example, using <a href="https://www.healthit.gov/isa/taxonomy/term/676/uscdi-v4" title="https://www.healthit.gov/isa/taxonomy/term/676/uscdi-" target="_blank">USCDI V4</a> for the <strong>Data Element – Body Weight</strong>, under the <strong>Data Class – Vital Signs</strong>, 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.</p>
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<div class="text-center">
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<figure class="figure">
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<a href="img/USCD-BodyWeight.png" target="_blank">
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<img class="figure-img img-fluid shadow text-center" style="height: 300px" src="img/USCD-BodyWeight.png" alt="Screenshot of USCD v4 website showing Body Weight Data Element"></a>
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<figcaption class="figure-caption">Screenshot of USCDI V4 - Body Weight</figcaption>
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</figure>
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</div>
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<br>
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<p>Here is the full list of <a href="https://www.healthit.gov/isa/sites/isa/files/2023-10/USCDI-Version-4-October-2023-Errata-Final.pdf" title="USCDI V4 Data Classes and Data Elements" target="_blank">USCDI V4 Data Classes and Data Elements</a>.</p>
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<blockquote class="blockquote">
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<h4><i class="fas fa-puzzle-piece"></i> Activity</h4>
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<p>Explore several of the data classes and elements featured under ASTP/ONC’s <a href="https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi#uscdi-v4" title="USCDI V4" target="_blank">USCDI V4</a> (such as Allergies and Intolerances – Substance Medication, Vital Signs – Systolic Blood Pressure, Procedures – Reason for Referral) and note the "Applicable Vocabulary Standard(s)."</p>
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</blockquote>
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<p>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.</p>
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