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 Diagnostic Imaging

Tests that result in visual images requiring interpretation by a credentialed professional.

Imaging Study - Content

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

Deanne Kasim Change Healthcare
Level 0 Cancer Care Surgical Procedure As Part of Treatment

Was a of surgery used as part of treatment for this diagnosis (e.g., Yes, No, Indeterminant)?
This is important minimal set information needed for coordinated care and understanding outcomes for public health policy

American Joint Committee on Cancer e.g. AJCC8

Charles Mayo, PhD University of Michigan
Level 0 Cancer Care Systemic Therapy As Part of Treatment

Was a of systemic therapy used as part of treatment for this diagnosis?
Yes
No
Indeterminant

American Joint Committee on Cancer e.g. AJCC8

Charles Mayo, PhD University of Michigan
Level 0 Cancer Care Radiation Therapy As Part of Treatment

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

Charles Mayo, PhD University of Michigan
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Physical Exam

Narrative clinical assessment of the Physical Exam results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Genetic Testing

Narrative clinical assessment of the Genetic Testing results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
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.

Mental Status Evaluation

Narrative clinical assessment of the Mental Status Evaluation.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Cancer Care Cancer Treatment Site of Recurrence

If there is a recurrence, then list sites of recurrence . The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were Primary- None Primary - Prostate Primary - Seminal Vesicles Nodal-None Nodal-Pelvic Nodal-Aortic Nodal-Distant Distant-None Distant- CHAARTED-Low Volume Distant- CHAARTED-High Volume Metastatic-Bone Metastatic-Viscera In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Evaluation Site of Recurrence can be selected e.g. Primary- None,Nodal-Distant

Charles Mayo University of Michigan
Level 0 Cancer Care Cancer Treatment Evaluation Basis of Disease Status

What measures were used in the determination of the disease status.
The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were

Physical exam

PSA

Plain film radiographs

Bone scan

Magnetic Resonance Imaging

Computed Tomograph

Biochemical marker (PSA)

PET-CT (PSMA)

PET-CT (F-18 fluciclovine)

PET-CT (C-11 choline)

In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Evaluation Basis of Disease Status can be selected e.g. PSA, MRI

Charles Mayo University of Michigan
Level 0 Cancer Care Radiation Therapy Dose Objective Value

Desired value for the specified Dose Objective

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Dose Objective Condition

Desired relationship of the Dose Objective to the Value Standard Values (List): = < <= > >= ALARA

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Dose Objective

TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of DVH metric for the objective

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Number Of Sessions in Course

Total number of sessions in the treatment course. A session is the period between when the patient enters the treatment room and when they leave it.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Volume

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

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Volume

Name of target volume structure for radiation therapy (e.g. Prostate).

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Volume

Identify targets and overall doses treated with the radiation therapy course. This supports systematic reporting what was done for treatment summaries. For example it enables identifying that the prostate received a dose of 7200 cGy. Where the prescription reflects intent, this element reflects what was delivered.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course - Involves Reirradiation

Does the radiation field for the current course overlap with radiation fields from prior courses of therapy?

Elizabeth Covington University of Michigan
Level 0 Cancer Care Pathology Molecular Test Name

Name of the molecular pathology test used as part of diagnosis and staging. There are a wide range of tests. In the case of prostate cancer values include:
DECIPHER
Prolaris
Oncotype DX Genomic Prostate Score
ProMark

American Joint Committee on Cancer e.g. AJCC8

Charles Mayo, PhD University of Michigan
Level 0 Cancer Care Provider Reported Toxicity Measure

For each Cancer Patient - Provider Reported Toxicity record the Toxicity Measure specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) is used then the Toxicity Measure would correspond to CTCAE Term (e.g. Dry Mouth, or Dry Mouth)

The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy

Common Terminology Criteria for Adverse Events
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…

Charles Mayo University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Unit

Unit corresponding to numerical value of radiation dose (e.g. cGy)

Elizabeth Covington University of Michigan