USCDI Export for the Public

Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service.

Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html

If not a single birth then the order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.).

FHIR patient extension: birthplace FHIR patient address.period

This is the address start and end date. The time period is important in determining the current address versus address at diagnosis.

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

Medicare Beneficiary Identifiers (MBI) used to uniquely identify Medicare patients.

MBI format specifications: https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf HL7 Identifier type value set, see MC (http://hl7.org/fhir/R4/v2/0203/index.html)

Patient vital status of alive/dead.

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

standard date formats

Numeric or alphanumeric code that uniquely identifies a document.

Indicates who or what performed the medication administration and how they were involved.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

This is a unique identifier that uniquely identifies mobile health application instance as installed on a mobile device. Related data elements would include Application name, App Builder, version, build number, hosting device, unique identifiers [similar to a Vehicle Identification Number (VIN) used to track and identify individual vehicle]. Unique Mobile Health Application Identifier enables identification of application instance to facilitate recall, maintenance, transparency and traceability.

The way a tumor acts within the body, e.g., ability to grow, invade other areas and/or metastasize.

Tumor Histologic Type: International Classification of Diseases for Oncology 3.2, with additional values accepted by the WHO-IARC but not included in the official published documents. SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, 2021 Release (month TBD) Tumor Behavior: International Classification of Diseases for Oncology 3.2 Tumor Primary Site: International Classification of Diseases for Oncology 3.2. SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release Tumor Laterality: SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release – mCODE Laterality Value Set Tumor Clinical Grade: North American Association of Central Cancer Registries Grade Clinical

Data elements or description that provide a woman's pregnancy history at the time of death.

"LOINC: Summary of death note: 47046-8 Physician Summary of death note: 83796-3 Nurse Summary of death note: 84273-2 US Standard Certificate of Death Hepatitis C Case Report Form "LOINC Codes for death note summaries: https://loinc.org/47046-8/ https://loinc.org/83796-3/ https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Pregnancy History - While a one to one relationship may not exist between the information in the EHR and what is needed in a state's electronic death registration system (EDRS), the information in the EHR (even if available in longhand), can help inform filling out the following in the EDRS. IF FEMALE: □ Not pregnant within the past year □ Pregnant at the time of death □ Not pregnant, but pregnant within 42 days of death □ Not pregnant, but pregnant 43 days to 1 year before death □ Unknown if pregnant within the past year Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf"

Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative)

LOINC—although we would like to see the set of codes constrained as suggested above. In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability.

Documentation about expected but pending or ongoing orders, interventions, encounters, services, and procedures for a patient.

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.

A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting.

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.

Documentation of a clinical encounter that takes place in an outpatient setting. Reason to consider separately (including this here because the "Reason" field for additional elements is truncating my text): This data element has some overlap with other existing and proposed Clinical Notes data elements Outpatient is a setting versus a type of service (Consultation, History & Physical, Discharge Summary, Transfer Summary, etc.). For example, Outpatient consultation notes span the “Consultation Note” and “Outpatient Note” data elements. However, we feel it is important to specify this particular setting because the vast majority of LOINC terms representing outpatient clinical notes aren’t captured in the data elements that represent particular types of service.

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.

Documentation of a clinical encounter that takes place via telehealth.

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.

"Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge."

"LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge"

A clinical note which narratively summarizes the patient encounter. LOINC code = 67781-5.

LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/

Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component.

LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/

Outpatient note, LOINC code = 34108-1, and any LOINC LongName which has the phrase or concept 'outpatient note' within it.

LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/