Table 1.
Sections and Vocabularies of the CCD and Modules Examined in this Research.
| Clinical Content Modules in C32 Standard | Primary Vocabulary for Clinical Content | Required by C32 Standard | Required by Stage 1 EHR Testing Procedures | Extracted with CCD Parser |
|---|---|---|---|---|
| Advanced Directive | Systematized Nomenclature of Medicine (SNOMED CT) | |||
| Allergy & Drug Sensitivity | Uniform Ingredient Identifier (UNII) & RxNorm | Medication Allergies Only | ✓ | |
| Comment | Free Text | |||
| Condition (Problems) | SNOMED CT & International Classification of Diseases (ICD)* | ✓ | ✓ | |
| Encounters | Uniform Billing (UB) Standard | |||
| Healthcare Provider | National Provider Identifier | |||
| Immunizations | Vaccine Value Sets | |||
| Insurance Provider | X12 Billing Standard | |||
| Language Spoken | Language Value Set | ✓ | Implied, but not specified | |
| Medication | RxNorm | ✓ | ✓ | |
| Person Information | Free Text & HL7 | ✓ | ✓ | ✓ |
| Plan of Care | Free Text | |||
| Procedure | SNOMED CT, ICD and Current Procedural Terminology (CPT)* | Required for hospital but not ambulatory CCD exchange | ||
| Results | Logical Observation Identifiers Names and Codes (LOINC) | ✓ | ✓ | |
| Support | Free Text & HL7 | ✓ | Implied, but not specified | |
| Vital Signs | LOINC |
*
While the HITSP preferred vocabulary for problems and procedures is SNOMED, the Final Rule for EHR certification provides flexibility for other vocabularies as specified in the Table 1.
Note: Information Source and Pregnancy status are modules not included in the above table since they overlap with content provided in the CCD header and condition modules.