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 2 | Facility Information | Physical place of available services or resources. |
Facility Managing Organization Identifier | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry | ||
| Level 2 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Collection Method | This is the collection method of the specimen sent for laboratory testing. | Sanjeev Tandon on behalf of CDC | CDC | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Negation Rationale | Joel Andress | CMS | |||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Group Name | Name of the Employer Account. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Reaction Severity | The clinical assessment of a specific allergic reaction when it occurs (e.g., mild, moderate, severe). | From SNOMED CT Implementation Guide for Allergy, Hypersensitivity and Intolerance: As a result of a request from HL7 to SNOMED International about the possibility of mapping some of the required HL7® FHIR® Value Sets to SNOMED CT, an analysis of the ability of SNOMED CT to accommodate those needs was performed by the SNOMED CT on FHIR Workgroup. The required value sets of the FHIR AllergyIntolerance resource were included in this analysis. AllergyIntolerance.Reaction.Severity It was assessed that there was a good match between the HL7 required value set and the SNOMED CT << 272141005 |Severities (qualifier value)| subhierarchy. |
Mr. Charles Gabrial | Federal Electronic Health Record Modernization (FEHRM) Office | |
| Level 2 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Appointment | A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s). | Philip Lieberman | Analog Informatics Corporation | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Dispense Quantity | The amount of medication dispensed or to be dispensed. |
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| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration | A record of a patient actually consuming a medicine, or if it has otherwise been administered to them. https://www.hl7.org/fhir/medicationadministration.html | Joel Andress | CMS | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration | A record of a patient actually consuming a medicine, or if it has otherwise been administered to them. https://www.hl7.org/fhir/medicationadministration.html | Shelly Spiro | Pharmacy HIT Collaborative | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Plan Identifier | Business concept used by a health plan to describe its benefit offerings. | Mark Roberts | Leavitt Partners | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Plan Name | Name of the health plan benefit offering assigned to the Plan Identifier. | Mark Roberts | Leavitt Partners | ||
| Level 2 | Immunizations | Record of vaccine administration. |
Immunization Status | Indicates the current status (i.e., completed, entered in error, not done) of the immunization event. |
Maria Michaels | CDC | ||
| Level 2 | Immunizations | Record of vaccine administration. |
Vaccination Event Record Type | Indicates whether the vaccination event is based on a historical record (e.g., second hand knowledge of the vaccination event) or was administered at the facility submitting the data. |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| Level 2 | Travel Information | Travel History Dates | The dates spent in a location traveled to. |
§ SNOMED: 420008001 |Travel (event)| |
Craig Newman | Altarum | ||
| Level 2 | Travel Information | Travel History Location | A location in a person’s travel history either as an address or as a coded location. |
1. SNOMED: 420008001 |Travel (event)| 2. Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) 3. ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 2 | Nutrition and Diet | Enteral Nutrition Type | Enteral Nutrition is the delivery of nutrients to a functional segment of the gastrointestinal tract distal to the oral cavity employing the use of a tube or catheter device to supply a liquid formula. This data element is for the type or brand name of the enteral formula. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Facility Information | Physical place of available services or resources. |
Facility Contact Information | Keith W. Boone | Audacious Inquiry | |||
| Level 2 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Processing Facility | Provides details on the processing location of the product |
ISBT-128 Processing Facility Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) |