USCDI Export for the Public

An objective lack of social contact with others. (National Academies of Sciences, Engineering, and Medicine, Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System, p. xi (2020).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

A subjective state that arises when an individual recognizes a situation as threatening, but dealing with the threat requires more resources than the individual has available. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 76 (2014).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

Radiation dose delivered to the target volume in fulfilling the prescription (e.g. 7200 cGy).

Violence between individuals, subdivided into family and intimate partner violence and community violence. (World Health Organization, World Report on Violence and Health, p. 6 (2002).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

The knowledge and skills gained through education, the credentialing linked to the completion of various levels of schooling, and the quality of education. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 68 (2014).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

Representation of the content produced in a DICOM imaging study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

DICOM

The reason why the hearing screen was not done in right ear.

73742-9 - Newborn hearing screen reason not performed of Ear - right (including Example Answer List LL2769-9)

Common food substances and allergens that can cause harmful or undesirable physioloical responses when exposed to the substance or the substance is consumed.

SNOMED CT with a value set created in VSAC (OID: 2.16.840.1.113762.1.4.1186.3) HL7 Cross Paradigm Specification: Allergy and Intolerance Substance Value Set(s) Definition: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=482 was used to create the value set

This data element includes the mass/volume of ethanol present in blood

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

Stents
Monitors
Pumps
Defibrillators

ICD 10, SNOMED, LOINC, RxNorm

Oxygen
Hoyer
Special fit wheelchair
Bariatric
Extended length
Wound care
VAC
Prosthetics, orthoses

ICD 10, SNOMED, LOINC, RxNorm

Healthcare service location within a facility where the procedure was performed.

Location of Procedure: HSLOC (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Transmission-based precautions: SNOMED CT

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 Medications data class

SNOMED CT codes for therapeutic intent (qualifier value)

Important drug-drug interactions
High risk medications e.g.:
anticoagulants
opiates
sedatives
electrolyte altering
hypoglycemics
antipsychotics
Immunosuppressants
Tricyclic antidepressants
Complicated regimens e.g.:
loading
tapering
sliding scale
precise schedule
Instructions for missed or late medications

ICD 10, SNOMED, LOINC, RxNorm

APGAR score post-birth including scores at 1, 5 and 10 minutes.

LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score

The hearing screening result for the leftear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear.

54108-6 - Newborn hearing screen of Ear - left (including Preferred Answer List LL618-0)

The number of fetal deaths in this delivery.

LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive

This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing using assessments coded with LOINC.

LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966

The hearing screening result for the right ear provides coded result values for pass, refer and not performed. There should be separate results for both the right Ear and left ear.

54109-4 - Newborn hearing screen of Ear - right (including Preferred Answer List LL618-0)

Was a of radiation therapy used as part of treatment for this diagnosis ? This is important minimal set information needed for coordinated care and understanding outcomes for public health policy
Yes
No
Indeterminant

American Joint Committee on Cancer e.g. AJCC8