USCDI Export for the Public
| Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
|---|---|---|---|---|---|---|---|---|
| Level 2 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Outcome | Outcome of the event – i.e. death, hospitalization, fever |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | |
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Medical Device Order | Provider-authored request for medical devices, such as for therapeutic footwear or walking aids. | SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging Reference | The technical details of the retrieval access path to indicate network services that can be used to access DICOM studies, series, or instances content and metadata (e.g., a DICOMweb server endpoint providing QIDO-RS, WADO-RS, or WADO-URI). | LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures |
Brian Bialecki | American College of Radiology | |
| Level 2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI | LOINC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 2 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Referral note | Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Group Name | Name of the Employer Account. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 2 | Immunizations | Record of vaccine administration. |
Vaccination Event Record Type | Indicates whether the vaccination event is based on a historical record (e.g., second hand knowledge of the vaccination event) or was administered at the facility submitting the data. |
LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ PHINVAD Immunization Information Source |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 2 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event | An adverse event is any undesirable experience associated with the use of a medical product in a patient. |
SNOMED CT (e.g., Life-threatening severity) |
Mitra Rocca | Food and Drug Administration | |
| Level 2 | Immunizations | Record of vaccine administration. |
Immunization Status | Indicates the current status (i.e., completed, entered in error, not done) of the immunization event. |
Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html |
Maria Michaels | CDC | |
| Level 2 | Healthcare Information Attributes | Contextual information that provides supporting details for healthcare data. |
Report Date | The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.), completes collection of data for the report. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Criticality | Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. | HL7 FHIR R4 Allergy Intolerance Criticality, Rx Norm, SNOMED CT, National Drug Code (NDC) |
Sandi Mitchell | J P Systems, Inc. | |
| Level 2 | Advance Directives | Healthcare Agent | Individual legally authorized to make healthcare decisions on behalf of a patient. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | |||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator | Indicates if the individual is deceased or not. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Nutrition Order | A clinician (provider)-authored request for a diet, formula feeding (enteral), or nutritional supplement. | SNOMED CT |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| Level 2 | Nutrition and Diet | Enteral Nutrition Type | Enteral Nutrition is the delivery of nutrients to a functional segment of the gastrointestinal tract distal to the oral cavity employing the use of a tube or catheter device to supply a liquid formula. This data element is for the type or brand name of the enteral formula. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Medical Device Status | Information beyond the UDI is required for patient care and clinical research. If a patient record is transferred to a new provider, the implant date of all active and inactive devices as well as the explant date of previously implantable devices is relevant. To conduct safety and effectiveness research, implant date, explant date and therapy status are relevant. Proposing implanted/inactivated/reactivated/explanted as the status values and that the status history is included as opposed to only current status. | NCI Thesaurus |
TICIA Louise GERBER | Health Level Seven International | |
| Level 2 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event Date | When the event occurred |
adverse events are mapped to MedDRA terminology |
Mitra Rocca | Food and Drug Administration | |
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Accommodation | Provides information or details regarding modifications, tools, technologies, and/or other supports needed in order to address any barriers to care that an individual living with a disability(ies) may need in order to improve their care and life with a diagnosis. |
Grace Cordovano | Enlightening Results |