The data critical for measuring health equity, social drivers of health (SDOH), and social risk factors requires numerous categories of information. Measured entities have not traditionally collected many of these categories, e.g., sexual orientation and housing status), and others are not collected consistently (e.g., race and ethnicity). Standardization of health data, equity data included, is essential for interoperability, which is a CMS priority. The CMS Office of Minority Health white paper, The Path Forward: Improving Data to Advance Health Equity Solutions, discusses current challenges and how CMS plans to expand the collection, reporting, and analysis of standardized data and use of health equity data to achieve equity goals.

An example of data standardization work is the Gravity Project, a Health Level Seven International® (HL7®) Fast Healthcare Interoperability Resources® accelerator project. The Gravity Project convenes interested parties across the U.S. to develop and test consensus-based standards to facilitate SDOH data capture and exchange across systems, care settings, and social services. Currently, the Gravity Project identifies data elements and associated value sets to represent SDOH information in electronic health records (EHRs) across four clinical activities: screening, diagnosis, goal setting, and interventions. The Gravity Project submitted SDOH-related data elements for inclusion in the United States Core Data for Interoperability (USCDI). The Office of the National Coordinator for Health Information Technology (ONC) incorporated these data elements into USCDI version 2.

A second example of standardization is HL7's Gender Harmony Project (GHP). GHP developed a gender-inclusive logical model. To classify individuals, the Model identifies sex as male, female, or specified and can be based on anatomy, other biological characteristics, or physical and physiological features. The Model defined gender "as a person's inner sense of being a girl/woman/female/feminine, boy/man/male/masculine, nonbinary, ..., something else, or having no gender" (McClure et al., 2022, p. 355). The purpose of the Model is to provide clinicians with information to support informed and safe health care for every patient.

CMS and others, e.g., Blue Cross Blue Shield of Illinois recommend collecting SDOH issues and coding them in the patient's record with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes. This aligns with USCDI v2 data element SDOH Problems/Health Concerns.

Z Code Categories

• Z55 - Problems related to education and literacy
• Z56 - Problems related to employment and unemployment
• Z57 - Occupational exposure to risk factors
• Z58 – Problems related to physical environment
• Z59 - Problems related to housing and economic circumstances
• Z60 - Problems related to social environment
• Z62 - Problems related to upbringing
• Z63 - Other problems related to primary support group, including family circumstances
• Z64 - Problems related to certain psychosocial circumstances
• Z65 - Problems related to other psychosocial circumstances

Each Z Code category has subcategories, for example

• Z55 - Problems related to education and literacy
  • Z55.0 Illiteracy and low-level literacy
  • Z55.1 Schooling unavailable and unattainable
  • Z55.2 Failed school examinations
  • Z55.3 Underachievement in school
  • Z55.4 Educational maladjustment and discord with teachers and classmates
  • Z55.5 Less than a high school diploma
  • Z55.6 Problems related to health literacy
  • Z55.8 Other problems related to education and literacy
  • Z55.9 Proble,s related to education and literacy, unspecified

While Z Codes have been available for some time, measured entities have not been using them regularly or consistently, as insurers do not require their use. To address the gaps in standardized collection of Z codes, CMS has developed an infographic for health care administrators and other team members to understand the best practices and importance of both gathering and tracking SDOH data.