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 0 | Pregnancy Information | Gestational Age Determination Method | Method for estimating gestational age, e.g., ultrasound, date of LMP. |
Value Set: Estimated Date of Delivery Including Method (https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.81/expansion) |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Pregnancy Information | Gestational Age Determination Date | The date on which the estimated gestational age of pregnancy was determined. |
Value Set: Estimated Date of Delivery Including Method (https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.81/expansion) |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory Test Performed Date | The clinically relevant date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained. |
Laboratory Test/Panel Code: LOINC Codes: http://loinc.org Laboratory Test Performed Date: FHIR dateTime, Period, Timing, Instant: http://hl7.org/fhir/observation-definitions.html#Observation.effective_x_ Laboratory Result Status: FHIR Observation Status: http://hl7.org/fhir/valueset-observation-status.html Laboratory Result Value: FHIR Quantity|CodeableConcept|string|boolean|integer|Range|Ratio|SampledData|time|dateTime|Period: http://hl7.org/fhir/observation-definitions.html#Observation.value_x_ |
Maria Michaels | CDC | |
| Level 0 | Patient Summary and Plan | Information that guides treatment of the patient and recommendations for future treatment. |
Treatment Change | Treatment Change documents the reason for changes to the plan of treatment plan. The options for this data element are, for example: no change (continue treatment), planned change, no response to treatment, adverse reaction, patient request for alternative treatment. The first option (no change in treatment plan) can document a review of the treatment plan that did not require in a change of treatment. |
LOINC, SNOMED-CT, and FHIR see: https://search.loinc.org/searchLOINC/search.zul?query=functional+status http://hl7.org/fhir/us/mcode/ https://browser.ihtsdotools.org/?perspective=full&conceptId1=273472005&edition=MAIN/2020-07-31&release=&languages=en |
Andre Quina | MITRE | |
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory results: date and timestamps | Date and timestamps associated with the completion of laboratory results, that are meta data associated with laboratory results |
LOINC codes for labs—date and timestamps collected in standard format |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication List Type | Codification of the type of medication list (e.g. Active medication list, Reconciled medication list, Discharged medication list, Discontinued (Inactive) medication list, Patient generated medication list (Different nuance, needs to be reviewed by a clinician before it can be entered as an active medication list), Medications that are private and need patient consent to share, Medication administration list, Medication administration list for public health and CDC reporting (e.g., for COVID, Antibiotics for Antibiotic Stewardship), Discharged medication list (Feeds the discharge summary that contains the Discharged medication list and when transferring within a hospital from one level of care to another (intersystem), a transfer medication list is used for MR). |
LOINC |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Cause of Death | Cause of death information includes the sequence of events leading to death as well as other conditions significantly contributing to death. The underlying cause of death may be different than the terminal condition. This may include summary of death note, and/or death information that may be captured within the discharge summary note or other cause of death documentation within the clinical notes section. |
LOINC: Summary of death note: 47046-8: https://loinc.org/47046-8/ Physician Summary of death note: 83796-3: https://loinc.org/83796-3/ Nurse Summary of death note: 84273-2: https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Supporting Links: PHINVADS Value Set: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3593 |
Maria Michaels | CDC | |
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Data Steward | Patients may be their own data stewards, or have other data stewards able to authorize permissions on their data. This term, "Data Steward" is intended to describe an individual or organization authorized and accountable for permission decisions about the health data of the individual. While this may be a RelatedPerson or a member of a CareTeam (existing elements and classes in USCDI FHIR), it may also not be part of those groups. Data stewards may be needed for individual patients who are incapacitated or for minors who lack legal capacity to consent (although be able to assent). Data stewards may also have a critical role in stewardship of health data for deceased individuals, e.g. clinical genetic counseling, research studies. Individuals may also assign stewardship to multiple individuals and organizations. Data stewardship may also authorize designated organizations and/or individuals to determine data use permissions by specific segment (e.g. medication data vs. family history data). |
FHIR has standards for Person and Organization resources: https://www.hl7.org/fhir/person.html https://www.hl7.org/fhir/organization.html However, role-specific terminology and standards may be needed to describe the specific role(s) of a Data Steward if considered as a separate element, or as a member of the CareTeam. |
Henry Wei | ||
| Level 0 | Research Data | Study Name | Study subject is part of |
CDISC standards, HL7 FHIR researchstudy, researchsubject (formerly known as Data Access Framework (DAF)) |
Mitra Rocca | Food and Drug Administration | ||
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity uncorrected left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity corrected right eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity logMAR left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Left eye Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79893-4 |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
Kerry Goetz | NIH/NEI | |
| Level 0 | Work Information | Job Employer Phone | Phone number of the individual's employer. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| Level 0 | Work Information | Job Title | Name of the job position held by an individual. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administrations Report (Flowsheet) | Structured data captured in a Medication Administration Report (usually for inpatients) showing each drug administered, who administered it, what time it was administered, etc. |
LOINC has codes for flowsheet elements/structured clinical data including for prenatal, cancer staging, and medication administration (clinical LOINC), FHIR R4 Observation resource, MedicationAdministration, among others, can be used to communicate the information. |
TICIA Louise GERBER | Health Level Seven International | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity corrected left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity uncorrected right eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | 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. |
M3 Results | M3 Results is the output from an evidence-based, 27 question, patient rated cross cutting mental health assessment. The output is a score that is highly predictive of any mental health condition, 4 clusters for risk of anxiety, PTSD, bipolar disorder and depression and the responses to the 27 questions. Together the data elements provide clinicians and patients results that enable de-stigmatized care by providing scores and longitudinal monitoring based on those scores to hopefully drive better outcomes. M3 is used by LabCorp and others and qualifies for a Standard based on its interoperability through their network. |
M3 has LOINC Codes M3 Score is an algorithm to allow a person to take a rated self-test and their clinician receive a structured report which includes a score that shows: 1) an assessment of an individuals risk of suffering from any mood disorder, and 2) a patient on a clinical map showing if they have a low, medium or high risk for each of the following: Depression, Anxiety, Bipolar, PTSD. In addition to the clusters, the report the answers for each report are included as structured data with all scores and responses having LOINC codes. |
Michael Byer | M-3 Information, LLC | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Device Settings | Patient-specific settings associated with a device. |
Device Type: SNOMED (Implanted port-central lines and tunneled hemodialysis catheters; Non-implantable devices would include ventilators, temporary central lines, urinary catheters) Location of Device Initiation: HSLOC code system (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Device Settings: LOINC (fraction of inspired oxygen, pressure support, positive end-expiratory pressure, ventilator mode, tidal volume delivered, frequency/respiratory rate setting - delivered by the ventilator) Device Observations / Measurements: LOINC (peak pressure, plateau pressure, spontaneous tidal volume, respiratory rate - spontaneous that the patient breaths) Device Route: type of airway (nasal cannula, facemask, endotracheal tube, tracheostomy) - delivery, approach - Feedback requested Device Status: related value sets: http://hl7.org/fhir/R4/valueset-device-status.html (active, inactive) or http://hl7.org/fhir/ValueSet/metric-operational-status (on, off, standby) - weaning trial - may be a property of the Procedure - Feedback requested |
Sheila Abner | CDC/NHSN |