Key Data Elements for EHR to Registry Lab Data Exchange
| Data Element | Req | Description | FHIR U.S. Core Mapping | U.S. Core Requirements¹ | Comments |
|---|---|---|---|---|---|
| Patient ID | ☑ |
[FK] Link to Patient Table | Observation.subject | [S] 1..1 |
|
| Lab Test Name [Code] | ☑ |
Identifier (code) for the lab test | Observation.code.Coding.code | [S] 1..1 |
A component of the CodeableConcept data type. |
| Lab Test Name [CodeLabel] | ☑ |
Display name/description for the lab test | Observation.code.Coding.display | [S] 1..1 |
A component of the CodeableConcept data type |
| Lab Test Name [CodeSystem] | ☑ |
Coding system that assigned the test identifier | Observation.code.Coding.system | [S] 1..1 |
A component of the CodeableConcept data type. US Core requires that LOINC be used if the test is represented in LOINC. In FHIR, codes from different coding systems can be sent because the datatype allows repeats. In the registry, codes from LOINC go here as the primary terminology codings. |
| Lab Test Date | ☑ |
Date laboratory test was performed | Observation.effectiveDateTime | [S] 0..1 |
The Clinically relevant time/time-period for observation. |
| Lab Test Unit [Code] | Identifier (code) for the reported units of measure | Observation.valueQuantity.code | [S] 0..1 |
A component of the Quantity data type | |
| Lab Test Unit [CodeLabel] | Display name for the reported units of measure | Observation.valueQuantity.unit | [S] 0..1 |
A component of the Quantity data type | |
| Lab Test Unit [CodeSystem] | Coding system that assigned the unit identifier | Observation.valueQuantity.system | [S] 0..1 |
A component of the Quantity data type. US Core requires (SHALL) use of UCUM for coded quantity units. | |
| Lab Test Value [Code] | Identifier (code) for the lab test result value | Observation.valueCodeableConcept.Coding.code | [S] 0..1 |
A component of the CodeableConcept data type | |
| Lab Test Value [CodeLabel] | Display name for the lab test result value | Observation.valueCodeableConcept.Coding.display | [S] 0..1 |
A component of the CodeableConcept data type | |
| Lab Test Value [CodeSystem] | Coding system that assigned the identifier for the last test result value | Observation.valueCodeableConcept.Coding.system | [S] 0..1 |
A component of the CodeableConcept data type. US Core recommends (SHOULD) use of SNOMED CT for coded result values. | |
| Lab Test Value Numeric | Numerical value of the lab test result (with implicit precision) | Observation.valueQuantity.value | [S] 0..1 |
A component of the Quantity data type | |
| Reporting Lab Test Name [Code] | Identifier (code) for the lab test, as assigned by the reporting laboratory. | Observation.code.Coding.code | [S] 1..1 |
A component of the CodeableConcept data type. In FHIR, codes from different coding systems can be sent because the datatype allows repeats. In the registry, codes from reporting lab go here as additional terminology codings. Distinguishing the "reporting" lab's internal codes from standard (LOINC) codes is handled by the "Coding.system"element. | |
| Reporting Lab Test Name [CodeLabel] | Display name/description for the lab test, as assigned by the reporting laboratory. | Observation.code.Coding.display | [S] 1..1 |
A component of the CodeableConcept data type. Distinguishing the "reporting" lab's internal codes from standard (LOINC) codes is handled by the "Coding.system"element. | |
| Reporting Lab Test Name [CodeSystem] | Coding system that assigned the test identifier, i.e. the coding system managed by the reporting laboratory. | Observation.code.Coding.system | [S] 1..1 |
A component of the CodeableConcept data type. Distinguishing the "reporting" lab's internal codes from standard (LOINC) codes is handled by the "Coding.system"element. | |
| Test Method [Code] | Identifier for specifying the mechanism or technique used to perform the observation. | Observation.method.Coding.code | 0..1 |
A component of the CodeableConcept data type. In FHIR, this optional method attribute is used if the method is not implicit in the code for Observation.code and/or a greater level of specificity is desired. | |
| Test Method [CodeLabel] | Display name/description for the mechanism or technique used to perform the observation. | Observation.method.Coding.display | 0..1 |
A component of the CodeableConcept data type. | |
| Test Method [CodeSystem] | Coding system that assigned the identifier for method code. | Observation.method.Coding.system | 0..1 |
A component of the CodeableConcept data type. | |
| # | # | # | # | # | # |
| Lab Test Result Status | Categorization of the result value's status that indicates it's degree of finality. | Observation.status | 1..1 |
Not a requirement in the final registry data table, but used in transformation pipeline. Status is required in the US Core profile. Per Cerner documentation, Status codes final, amended and corrected are supported. |
|
| Lab Test Identifier (Instance ID) | An instance identifier for this test result as assigned by the clinical institution. | Observation.identifier | 0..1 |
Present in clinical institution EDW extract. |
¹ See these descriptions of Flags and Cardinality in FHIR.