1 2020 Interoperability Standards Advisory Office of the National Coordinator for Health IT Reference Edition Table of Contents Introduction to the 2020 Interoperability Standards Advisory ................................................................................................ 1 Section I: Vocabulary/Code Set/Terminology Standards and Implementation Specifications ............................................... 2 Allergies and Intolerances ....................................................................................................................................................... 2 Clinical Notes .......................................................................................................................................................................... 4 Cognitive Status ...................................................................................................................................................................... 5 Demographics ......................................................................................................................................................................... 6 Dietary and Nutritional Needs ................................................................................................................................................ 7 Emergency Medical Services .................................................................................................................................................. 8 Encounter Diagnosis, Assessment and Plan............................................................................................................................ 9 Family Health History ........................................................................................................................................................... 11 Functional Status/Disability .................................................................................................................................................. 12 Goals ..................................................................................................................................................................................... 13 Health Care Providers, Family Members and Other Caregivers ........................................................................................... 13 Health Concerns .................................................................................................................................................................... 15 Imaging (Diagnostics, Interventions and Procedures) .......................................................................................................... 15 Immunizations ....................................................................................................................................................................... 16 Industry and Occupation ....................................................................................................................................................... 18 Laboratory ............................................................................................................................................................................. 19 Medications ........................................................................................................................................................................... 20 Nursing .................................................................................................................................................................................. 21 Patient Clinical “Problems” (i.e., conditions) ....................................................................................................................... 23 Preferred Language ............................................................................................................................................................... 23 Pregnancy Status ................................................................................................................................................................... 24 Procedures ............................................................................................................................................................................. 24 Provenance ............................................................................................................................................................................ 26 Race and Ethnicity ................................................................................................................................................................ 27 Research ................................................................................................................................................................................ 28 Sex at Birth, Sexual Orientation and Gender Identity ........................................................................................................... 29 Social, Psychological, and Behavioral Data ......................................................................................................................... 32 Tobacco Use (Smoking Status) ............................................................................................................................................. 39 Units of Measure ................................................................................................................................................................... 41 Vital Signs ............................................................................................................................................................................. 42 Section II: Content/Structure Standards and Implementation Specifications ....................................................................... 43 Admission, Discharge, and Transfer ..................................................................................................................................... 43 Care Coordination for Referrals ............................................................................................................................................ 45 Care Plan ............................................................................................................................................................................... 47 Clinical Decision Support ..................................................................................................................................................... 51 Clinical Quality Measurement and Reporting ....................................................................................................................... 54 Data Provenance ................................................................................................................................................................... 57 Diet and Nutrition ................................................................................................................................................................. 58 Drug Formulary & Benefits .................................................................................................................................................. 59 Electronic Prescribing ........................................................................................................................................................... 60 Family Health History (Clinical Genomics) ......................................................................................................................... 82 Healthy Weight ..................................................................................................................................................................... 83 Images ................................................................................................................................................................................... 84 Laboratory ............................................................................................................................................................................. 87 Medical Device Communication to Other Information Systems/Technologies ................................................................... 91 Patient Education Materials .................................................................................................................................................. 92 Patient Identification Management ....................................................................................................................................... 93 Patient Preference/Consent ................................................................................................................................................... 94 Public Health Reporting ........................................................................................................................................................ 95 Research .............................................................................................................................................................................. 106 Segmentation of Sensitive Information ............................................................................................................................... 112 Summary Care Record .......................................................................................................................................................