The purpose of this page is to capture the goals and requirements to enhance ELR reporting in the context of the COVID pandemic, and in that context provide clear guidance to all parties in the communication flow to enhance their contributions to enhance the ELR transaction to a Public Health Authority. 

This is meant to be a working document that we rapidly evolve based on latest understanding. Once it is believed to be sufficiently complete and accurate it will be published elsewhere as a guidance document.


Hans Buitendijk - Cerner, HL7 Orders & Observations Co-Chair, EHRA Standards & Interoperability Chair

David Burgess - LabCorp, HL7 Orders & Observations Co-Chair

Freida Hall - Quest Diagnostics

Jason Hall - CDC

Janet Hamilton - CSTE

Riki Merrick - APHL, HL7 Orders & Observations Co-Chair, IHE Pathology and Laboratory Medicine Co-Chair

Craig Newman - Altarum, HL7 Public Health Co-Chair

Andrea Pitkus- University of Wisconsin-Madison

Dan Rutz - Epic, IHE ???

Kathy Walsh - LabCorp

Michael Waters - FDA


Current Challenges

When ELRs are sent to PHA at times, they may not contain sufficient demographic, and other data as is necessary required by public health by law.  While some of that data could be part of a subsequent eCR, if the data is already available at time of order and ELR transmission before an eCR is available (or the next eCR is available) helps accelerate the process.

Although ELR has been required of all laboratories performing testing for reportable conditions, only Eligible Hospital labs have been required to send HL7 v 2.51 messages with LOINC and SNOMED CT codes conforming to each PHA jurisdiction's requirements for the past decade using a vendor system certified to provide functionality according to the HL7 ELR Guide in Meaningful Use regulations.  For the remainder of laboratories (i.e. blood banks, reference labs, government/DOD labs, independent labs), they need to meet each jurisdictions ELR requirements based upon the HL7 2.51 ELR IG, but may send messages in HL7 2.31 format, which may or may not contain LOINC or SNOMED CT codes or other fields.  If the PHA onboards the lab, they may accept a variety of fields, formats as long as they are receiving key information.  Also it's unclear if point of care testing locations like pharmacies, drive up/drive through testing sites or state national guard collection sites for COVID-19 are 1. reporting ELR at all, 2. providing all required information and 3.  those reporting on paper requisitions will not be providing LOINC or SNOMED CT codes and are often lacking demographics, specimen source and other required PHA elements. 

Through the process from ordering to reporting, there is a need to:

There are numerous challenges along in this flow in terms of data not being able to be collected, not being documented, not using standard vocabulary, not including it in the order, not forwarding certain data, dropping standard vocabulary, not retaining data, not communicating data available to the PHA.  The challenges this guidance is looking at is ensuring that the relevant data can be communicated from ordering provider through a potential intermediary lab to the performing lab and on to PHA as an ELR in a complete, standard, consistent format and with vocabulary.

Currently the specific challenges in that area are:

As indicated before, there are many other challenges to ensure that data if fully, accurately, and consistently documented and communicated, including use of encoded standard vocabulary (at least along with any local coding that remains relevant), but that is not addressed here.  Our goal is to provide guidance on how to address the above challenges in the necessary implementation guides that can be deployed as quickly as possible and as consistent as possible across ALL jurisdictions.

We understand that there may be a desire/need to send the original order to PHA directly as well to get earlier insight into certain tests ordered including PHI, particularly during an emergency (as that may invade patient privacy unnecessarily during "normal" situations), but when that interest becomes a requirement, the guidance for the ordering flow is sufficient as the starting point and being extended based on local PHA emergency mandates on how much (or not) PHI is to be removed before forwarding it.  That guidance should be as consistent as possible as well, but we will address that when an actual requirement in any jurisdiction is raised.


The following data set is desired to be made available as part of an ELR as much is is available upon placing the order and to the extent that the Laboratory has access to any additions before the ELR is sent.

Demographic Data

1Patient ageRequired-HHS
For reporting from PHA to CDC/HHS, when DOB may not be included
2Patient raceRequired-HHS
some jurisdictions used to not allow collection of this information - is that still the case? If so, will this superseed those regulations?
3Patient ethnicityRequired-HHS
some jurisdictions used to not allow collection of this information - is that still the case? If so, will this superseed those regulations?
4Patient sexRequired-HHS

5Patient residence zip codeRequired-HHS

Some jurisdictions consider a combination of age, sex and zipcode PII, because of the population densitiy - need to accommodate that by allowing creation of regions (and that may be better done in the county field)

6Patient residence countyRequired-HHS

Some jurisdictions consider a combination of age, sex and county PII, because of the population densitiy - need to accommodate that by allowing creation of regions

ELR requires use of numeric FIPS 5-2 codes

7Patient name (Last name, First name, Middle Initial)Optional-PHA
It is required for PHA, not desired for HHS
8Patient street addressOptional-PHA
It is required for PHA, not desired for HHS
9Patient phone number with area codeOptional-PHA
It is required for PHA, not desired for HHS
10Patient date of birthOptional-PHA
It is required for PHA, not desired for HHS

Order Data

1Ordering provider addressOptional-PHA
It is required for PHA, not desired for HHS
2Ordering provider phone numberOptional-PHA
It is required for PHA, not desired for HHS
3Ordering provider name and NPI (as applicable)Required-HHS
For some testing there may not be a specific ordering provider (e.g. employment related testing) - it is a CLIA requirement so need to ensure that this is provided
4Ordering provider zipRequired-HHS

For some low density areas, this may provide too much identification in the HHS feeds

Concern has been raised that this may be hard to decide which to pick, for providers, that have more than one practice location

5Date test ordered (date format)Required-HHS

6Test ordered – use harmonized LOINC codes provided by CDCRequired-HHS
Currently no order code look up available - nor guidance on which LOINC to pick for which order

Ask at Order Entry

SeqNameDefinitionOptionalityAllowable AnswersComments
1First test

2Employed in healthcare?

3Symptomatic as defined by CDC?

4Symptomatic = Y then Date of Symptom Onset

5Hospitalized? Y/N/U


7Resident in a congregate care setting (including nursing homes, residential care 
for people with intellectual and developmental disabilities, psychiatric treatment 
facilities, group homes, board and care homes, homeless shelter, foster care or other setting)

8Pregnant?Pregancy status of the patient

There are 2 LOINCs available 

Specimen Collection

1Date specimen collected (date format)Required-HHS
ELR allows use of 0000, when date is unknown

Test Result

1Performing facility name and/or CLIA number, if knownRequired-HHS

2Performing facility zip codeRequired-HHS

3Device IdentifierRequired-HHSIntent is to know which test has been performed where
4Test result – use appropriate LOINC code, as defined by the Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests provided by CDCRequired-HHSThis is refering to the performed test (observation.code in CDA/FHIR)
5Test result (value) – use appropriate SNOMED CT code as defined by the Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests provided by CDCRequired-HHSThis is referring to the result value (Observation.value in CDA/FHIR)

Some results can be numeric, and require units of measure, but no SCT code

some results could be longer text, specifically interpretations

SCT is required for qualitative result values

6Test Result date (date format)Required-HHS

Updates to Implementation Guides

The following updates need to be made in the base implementation guides for a next version to include the short-term Implementation Guidance provided in the next section.

Implementation Guidance


Device Identification

Mapping Spreadsheet

Use this spreadsheet to collect options and comments around the proposed mapping of the HHS elements to various places in Order and result messages.

Open questions on spreadsheet

Open Issues

Resources for Background