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 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Coverage Period | The time frame in which the policy is in force. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Policy Number | The unique identifier for a specific insurance policy that defines a set of covered benefits and services along with other information that is necessary to administer the policy (e.g. financial obligations for both parties) |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| Level 2 | Social History | Sexual Activity | Information on the sexual activity of the patient |
SNOMED CT: (Parent code and all children codes in the hierarchy) 414254005 - Finding of frequency of sexual activity (finding) 162171002 - Currently not sexually active (finding) 228453005 - Sexually active (finding) *LOINC 64728-9 - Have you ever had vaginal intercourse [PhenX] *Note Montana's Department of Public Health and Human Services (DPHHS) includes SNOMED CT codes in their “Adolescent Wellness” Registry, addressing the “STI Screening” measure, together with the “Chlamydia Screening in Women” measure. |
Raymonde Uy | National Association of Community Health Centers (NACHC) | ||
| 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 | ||
| Level 2 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition. |
Nutrition Assessment | A systematic nutrition assessment of an individual's nutrition intake, physical exam, anthropometric measurements, biochemical, and health condition data compared to accepted standards, recommendations, and/or goals to arrive at a determination of the client’s nutrition well-being or malnutrition. | Michelle Ashafa | Academy of Nutrition and Dietetics | ||
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Processing Facility | Provides details on the processing location of the product |
ISBT-128 Processing Facility Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Division | Provides details on aliquots or when a donation event involves more than one collection |
ISBT-128 Division Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Facility Information | Physical place of available services or resources. |
Facility Contact Information | Keith W. Boone | Audacious Inquiry | |||
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Source Identifier | Provides details on collections and pooled products such as donation identifier |
ISBT-128 Donation Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Unique Identifier | Provides a globally unique identifier code for an individual product. |
Medical Product of Human Origin Unique Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| 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. |
Mitra Rocca | Food and Drug Administration | ||
| 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 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Product Code | Provides a description of and supports traceability for a product |
ISBT-128 Product Description Code |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Device used | Devices are an identifiable grouping of mobility devices (i.e., wheelchairs), implantable devices (i.e., pace makers), or other wearable devices (i.e. compression socks or venous foot pump) with significant impact on patient functionality and health. The QDM v5.5 notes that “Device represents an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.” |
SNOMED CT (Frailty Device, value set OID: 2.16.840.1.113883.3.464.1003.118.12.1300) SNOMED CT (Intermittent Pneumatic Compression Devices (IPC), value set OID: 2.16.840.1.113883.3.117.1.7.1.214) SNOMED CT (Graduated Compression Stockings (GSC), value set OID: 2.16.840.1.113883.3.117.1.7.1.256) SNOMED CT (Venous Foot Pumps (VFP), value set OID: 2.16.840.1.113883.3.117.1.7.1.230) SNOMED CT (Cardiac Pacer, value set OID: 2.16.840.1.113883.3.526.3.1193) ICD-10-CM, SNOMED CT (Cardiac Pacer in Situ, value set OID: 2.16.840.1.113883.3.526.3.368) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Birth time | FHIR birthTime extension |
Kensaku Kawamoto, MD, PhD, MHS | University of Utah | ||
| Level 1 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition. |
Two-item PROMIS®️ global physical and mental health scales | Two-item PROMIS®️ global physical and mental health scales: Global health items provide synoptic information that can be utilized as predictive indictors of health care utilization and mortality. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Birth Place | The city, state, county and country or location in which the patient was born. |
FHIR patient extension: birthplace FHIR patient address.period |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 1 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Biologically Derived Product information | This set of data elements describes information related to the biologically derived product: a. Product Code (productCode): this is the data element which can store 1 to many codable concepts describing the product. We propose the ability to use the following product codes to identify biologically derived products: a.i. ISBT-128 Product Code: identifies the biologically derived product type, such as blood components, fluids, tissues, organs, or cells. a.ii. ISBT-128 Donation Identification Number: uniquely identifies a biologic product donation, such as blood components, fluids, tissues, organs, or cells. a.iii. NDC or RxNorm codes can be used for biologically derived products that are manufactured and labeled with an NDC, such as blood derived products (e.g. IVIG’s, clotting factors). Vaccines shall use the Immunization Data Class resource. b. Product Type/Category (FHIR R4: productCategory): this element identifies the product type (e.g. organ | tissue | fluid | cells | biologicalAgent). c. Collector (FHIR R4: collector): identifies the collection entity practitioner resource instance, if appropriate. d. Source (FHIR R4: source): linkage to Patient or Organization resource identifying the biologically derived product donation source. e. Collected date/time (FHIR R4: collected): date and time of biologic product collection. f. Quantity (FHIR R4: quantity): quantity of biologic product identified in the resource instance. |
ISBT-128 for biologically derived products of human origin (blood components, fluid, cells, tissues, or organs), and NDC/RxNorm for productized biologics such as blood derived products (e.g. IVIGs, clotting factors, and others). Links URLs (added here to enable sharing multiple): - ISBT: http://www.iccbba.org/tech-library/iccbba-documents/databases-and-reference-tables/product-description-codes-database2 - RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html - NDC: https://www.fda.gov/drugs/drug-approvals-and-databases/nati |
Barbee Whitaker | FDA Center for Biologics Evaluation and Research | |
| Level 1 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Biologically Derived Product Storage information | This set of data elements describe the product’s storage information within the blood bank or other appropriate entity storing the product: a. Description (FHIR R4: description): this is a free-text field for describing how the product is stored. b. Temperature (FHIR R4: temperature): temperature used for storage. c. Temperature Units (FHIR R4: scale): units for temperature used for storage (e.g. Celsius or Fahrenheit). d. Storage Duration (FHIR R4: duration): duration of storage before administration. |
ISBT-128 for biologically derived products of human origin (blood components, fluid, cells, tissues, or organs), and NDC/RxNorm for productized biologics such as blood derived products (e.g. IVIGs, clotting factors, and others). Links URLs (added here to enable sharing multiple): - ISBT: http://www.iccbba.org/tech-library/iccbba-documents/databases-and-reference-tables/product-description-codes-database2 - RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html - NDC: https://www.fda.gov/drugs/drug-approvals-and-databases/nati |
Barbee Whitaker | FDA Center for Biologics Evaluation and Research | |
| Level 1 | Facility Information | Physical place of available services or resources. |
Facility GPS Coordinates | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry |