United States Core Data for Interoperability (USCDI) is a term you are probably unfamiliar with, but it will soon affect every aspect of your practice. Here is what you need to know.

What’s USCDI?

USCDI is defined as a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.

USCDI started as a limited data set aimed at ensuring that a core set of patient health data could be shared. The initial data set in USCDI version 1, which is the current interoperability requirement in healthcare, did not include specialty data.

The 21^st Century Cures Act was enacted to require all medical providers to have the ability to share everything recorded electronically including all exam findings, financial information and administrative information. USCDI provides a path to progressively move toward that goal without putting too excessive a burden on either providers or EHR vendors. There is a process in place to add additional data elements to USCDI. The proposed rule that was open for public comment in April 2023 proposes that USCDI version 1 be replaced at the end of 2024 with USCDI version 3. That is significant in that USCDI version 3 includes specialty data.

You can see what data is required in USCDI version 3 by clicking HERE. It will bring you to the HealthIT.gov website where you can see a list of everything that is required in USCDI version 3. Click HERE to see what is required in USCDI’s other versions. USCID version 1 is the current requirement.  USCDI version 4, as you will see, is already being developed.

You should be familiar with everything that will be required, but pay particular attention to these three areas:

• Clinical Notes
• Clinical Tests
• Diagnostic Imaging

The clinical tests section is new in USCDI version 3. With these three requirements, everything you record during your exam is included in the data that you will be required to share if requested by any organization or entity that your patient has authorized to have their data, or by any other provider that needs your data in order to provide care to the patient. Additionally, not only will your interpretation of any diagnostic testing have to be interoperable, but also the tests themselves.

The 21^st Century Cures Act makes it clear that EHR vendors and you as a provider are equally responsible for meeting these requirements. It also requires the Attorney General’s office to put in place penalties for non-compliance. Although the penalties are not in place yet, it is anticipated they will be by the end of 2024 when USCDI version 3 is expected to replace USCDI version 1.

Create a Tracking Folder

It is pretty obvious that your EHR has to give you the technical capability to share this data, but it is your obligation to make sure you are also moving toward compliance. You may want to begin maintaining a folder that documents your efforts. That way, if you get involved in a non-compliance situation, you have a clear record to show that you have requested the functionality from your EHR vendor.

There are two things you should already have documented in your tracking folder:

• Every certified EHR system includes Direct Secure Messaging (DSM), and in order for your system to meet the maintenance of certification requirements, it must be turned on. If you remember, a few years ago, as part of Meaningful Use, you had to actually demonstrate that you used DSM once during the year to show that it works. Even though you don’t have to show that you are using it currently, the assumption is that your system is able and that you are using it to meet the next requirement.
• USCDI version 1 has been in effect for a few years. You are already required to be able to share the data listed in this version through DSM.

Your tracking folder should demonstrate that you are doing the activities that you are required to be doing now, as well as making sure you know the path your EHR vendor is taking to meet the requirements of USCDI version 3.

The documentation in your tracking folder should make it clear that you want to be able to meet those requirements when they become mandatory. If there is a non-compliance complaint against you or your office, the patient or organization making the complaint will report your office. They likely won’t even know which EHR system you use. If you have these steps documented, but your EHR vendor hasn’t given you the technical ability to comply, it will shift the focus of the Inspector General’s investigation to your EHR vendor.

This article is being written from a compliance standpoint. It is important to mention that the functionality of DSM, which enhances your ability to electronically communicate with other offices, brings significant value to your practice. Once you begin using this technology, you will quickly see how much more efficient it is than communicating through fax. Offices that are using these technologies have a competitive advantage over those that don’t. That is the most important reason to use this technology.

Key Steps to Take

If you complete following steps, you will not only bring value to your office immediately, but will have valuable documentation to show that you have done your part to ensure you are compliant:

• Make sure you have DSM turned on in your EHR system, your staff is trained on how to use it and you are really using it to communicate with other healthcare offices. Remember, every provider you are currently sending faxes to that uses a certified EHR also already has this capability.
• USCDI version 1 is already in effect. Your EHR vendor should already be providing you the ability to send out all the information required in this version through DSM. If you are not able to do this, you should get a written response from your vendor on what steps they are taking to make it possible for you to comply and the time period in which the functionality will be available.
• Make sure you have it clearly documented in your tracking folder that you expect your vendor to provide the technical ability to meet the requirements of USCDI version 3 by the time it takes effect.

HL7 International is the organization that creates the interoperability standards that are adopted by the Office of the National Coordinator (ONC) as certification requirements for your EHR system. HL7 International has a process that all EHR vendors are invited to participate in, which provides a collaborative process for them to work with other EHR systems to ensure that when you send out a DSM, other providers’ EHR systems will be able to receive and utilize the information.

Likewise, the process ensures that when you receive information from other healthcare offices, your EHR system is able to make that information available for you to use in a way that is efficient. It will be almost impossible for a vendor to meet the requirements of USCDI version 3 if they are not participating in this or another collaborative process. You should document in your folder whether your vendor is a member of HL7 and whether they are actively participating in a process to test and ensure their system is interoperable with all other EHRs.

Our country is rapidly advancing in the delivery of healthcare so that your success as a provider largely depends on how efficiently you can participate as part of the patient care team.

You can’t sit back and wait for other organizations or your EHR vendor to act. You need to learn how to use these new technologies and understand how valuable they are in opening new opportunities to expand and grow your practice.