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 1 | Advance Directives | Quality of Life Priorities | A PACP may contain a person’s quality of life priorities based on their personal values for what is important to them in order to have a good quality of life. They may value such things as being able to take care of themselves without needing physical help from loved ones, or being able to live without depending on machines to keep them alive, or living as long as possible by receiving all the medical care doctors believe will help them. The intent of the quality of life priorities is to provide guidance to the future care team, in a situation where the person is unable to communicate for his or her self, that informs their healthcare agent as to what is important to them and provides guidance to the care team when treatment decisions need to be made on the person’s behalf. |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Instrument Unique Identifier | Uniquely identifies the type of instrument that was used in conjunction with the Test kit (at minimum by using instrument name and manufacturer (similar to the make and model of a car)) to obtain the Test Result Value. When a testkit is used on an instrument it is the combination of kit and instrument, that qualify the Performed Test. |
Riki Merrick | Association of Public Health Laboratories | ||
| 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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Treatment Intent | The purpose of a treatment, or the desired effect or outcome resulting from the treatment. For example, a treatment may be intended to completely or partially eradicate a disease process by disrupting its underlying physiological processes, resulting in improvement in health; or a treatment may have no expectation of eradication but rather may be intended simply to delay the onset of more severe symptoms; or may be intended to prolong life without any expectation of cure. NOTE: Treatment Intent has also been submitted under the Procedures data class |
SNOMED CT codes for therapeutic intent (qualifier value) |
Andre Quina | MITRE | |
| 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. |
Promise Preference (PROPr) Utility Score | PROPr is a score for the PROMIS measurement system. PROPr combines scores from 7 PROMIS domains into a single preference-based score (also called a health utility score). This score captures the preferences of the general adult US population. |
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 Marital Status | Patient marital status at the time of documentation. |
Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion |
Maria Michaels | CDC | |
| 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 | Cancer Care | NCI Patient Reported Outcomes (PRO)-Common Terminology for Criteria for Adverse Events (CTCAE) | PRO-CTCAE (NCI Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events) was developed to evaluate symptomatic toxicities by self-report in adults, adolescents and children participating in cancer clinical trials. It is designed to be utilized in comparison to the Common Terminology Criteria for Adverse Events (CTCAE), the standard lexicon for adverse event reporting in cancer trials. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | ||
| Level 1 | Work Information | Combat Zone Period | This data element is the self-reported date range(s) when a person worked in what is considered a combat zone. Both civilian workers, such as Department of Defense contractors, and military service members could have worked in combat zones. |
An information model of the Patient Work data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation. Logical Observation Identifiers Names and Codes (LOINC; https://loinc.org/) codes are available for each Patient Work Data Element, including Employment Status. The ODH code set (https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.327) provides a value set for Employment Status as well as other Patient Work Data Elements (https://phinvads.cdc.gov/vads/SearchValueSets_search.action?searchOptions.searchText=ODH). The PHIN VADS ODH Hot Topics section provides downloadable files with Preferred Concept Names and Easy Read Descriptions for Employment Status values (https://phinvads.cdc.gov/vads/SearchVocab.action). Interoperability standard formats for all of the Patient Work Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References: HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/ HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516 . Chapter 2C, Tables, Tables 0954-0959 provide the Patient Work Data Element component value sets. Chapter 3, Patient Administration, sections 3.4.15 and 3.4.18 describe the Patient Work Data Elements Employment Status and Combat Zone Period as Occupational Health (OH) segments; Retirement Date is included in the PD-1 segment. |
Genevieve Luensman | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health | ||
| Level 1 | Special Alerts for Care Handoffs | Results LOINC | All pending results and contact information for how to obtain |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| Level 1 | Advance Directives | Personal Advance Care Plan | Advance care plan is a general term for any documentation or other recordation of a person’s medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. An advance care plan places an emphasis on communication, as opposed to legal formalities. A PACP is a term specifically defined by HL7 as a template to facilitate the sharing of information expressed in advance care plans. A PACP may include the type of information contained in a living will and/or a durable medical power of attorney, and it also may include other medical interventions experience preference and instructions that help a healthcare agent make treatment decisions on the person’s behalf, and can be used by medical professionals to inform their medical interventions and treatment planning for the patient. Within the family of documents that have been defined under Consolidated CDA, the PACP document can be classified as a type of patient-generated document. The PACP document facilitates digital exchange of information previously and currently captured and shared using paper documents. Digital exchange of this type of data has become particularly critical within the context of COVID-19. To reduce the spread of disease, hospitals have disallowed patient family members and/or representatives to be present when the patient is admitted and as medical interventions are rendered, while also prohibiting acceptance of paper documents due to concerns of contagion. A PACP may include information relating to the appointment of a healthcare agent and alternate agents and establishing their authorized powers and limitations. It also may include information relating to any or all of the following: goals, preferences, and priorities for medical interventions (e.g., palliative and/or hospice care), including medical treatment preferences, based on the patient’s individual values, spiritual and religious beliefs, and personal definitions of quality of life; instructions to be followed after death (e.g., organ donation and autopsy); and information about who has signed, witnessed, and notarized the information authored by the individual, if available and appropriate. The set of recognized kinds of advance directive documents include concepts from the value set: Advance Directives Categories urn:oid:2.16.840.1.113883.11.20.9.69.4 which is openly available for reference in the National Library of Medicine’s Value Set Authority Center. It can be referenced using this url: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.69.4/definition |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Airway Management | Patient history and assessments performed by healthcare providers which are used to identify airway management techniques used and potential complications. These elements are important for any patients undergoing airway management, whether in the emergency department, in the intensive care unit, or in the operating room for elective or emergent surgical procedures with anesthesia. |
Difficult tracheal intubation: Difficult mask ventilation: Mallampati scores: Video intubation: (glidescope) Intubation techniques: Difficult supraglottic airway ventilation |
Matthew Popovich | American Society of Anesthesiologists | |
| Level 1 | Work Information | Retirement Date | Retirement Date is a self-reported date (at least year) that a person considers themselves to have ‘retired’. A person can have more than one Retirement Date. A person can be both employed and retired, so these data are independent of one another. |
An information model of the Work Information data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation. Logical Observation Identifiers Names and Codes (LOINC) codes are available for each Work Information Data Element and each component of the data elements, including Retirement Date (https://loinc.org/). Interoperability standard formats for all of the Work Information Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References: HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/ HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516. Chapter 3, Patient Administration: Retirement Date is included in the PD-1 segment. |
Genevieve Luensman PhD | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH) | ||
| Level 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Social Security Number | Records patient’s social security number. |
Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion |
Maria Michaels | CDC | |
| Level 1 | Exposure/Contact Information | Exposure/Contact Direction | Whether the direction of exposure/contact is acquisition (patient is the target and another person, animal, location, etc. is the source) or transmission (patient is the source and another person, animal, location, etc. is the target). | HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: US Public Health Exposure Contact Information profile (Observation.component) HL7 CDA: Exposure/Contact Information Observation template (observation/participant) |
Laura Conn | |||
| 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. |
Terminal Illness Status | Recommended to have element for Terminal Illness Status in this Data Class in USCDI V3. This is a matter of interest to Next of Kin/Related Parties and of high value to Care Team (needed for revised Care Plan) and would immensely help with timely and seamless Transition and Coordination of Care between different settings and care givers. |
Terminal illness (Code 300936002) SNOMED code. https://www.hipaaspace.com/medical_billing/coding/snomed/300936002 https://www.findacode.com/snomed/162607003--terminal-illness-early-stag… https://build.fhir.org/ig/cqframework/opioid-cds-r4/ValueSet-limited-li… |
Dave Shekhar | ||
| Level 1 | Genomics | Gene Studied | The human gene targeted for mutation/variant analysis. |
SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Genomics | Variant Data | The data representing the genetic variant information itself. Depending on the type of genetic variation, this data element could contain representation of a genomic DNA change, amino acid change, etc. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Genomics | Variant Interpretation | The categorical or clinical assessment of the genetic variant data, where interpretation is necessary to fully understand the significance. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Exposure/Contact Information | Exposure/Contact Type | The type of exposure/contact (environmental, activity, event, location, person, animal, etc.) to an agent. | HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: US Public Health Exposure Contact Information profile (Observation.component) HL7 CDA: Exposure/Contact Information Observation template (observation/participant) |
Laura Conn |