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 | Adverse Events | Unintended effects associated with clinical interventions. |
Adverse Event | An adverse event is any undesirable experience associated with the use of a medical product in a patient. |
Mitra Rocca | Food and Drug Administration | ||
| Level 2 | Social History | Sexual Activity | Information on the sexual activity of the patient |
SNOMED CT: (Parent code and all children codes in the hierarchy) 414254005 - Finding of frequency of sexual activity (finding) 162171002 - Currently not sexually active (finding) 228453005 - Sexually active (finding) *LOINC 64728-9 - Have you ever had vaginal intercourse [PhenX] *Note Montana's Department of Public Health and Human Services (DPHHS) includes SNOMED CT codes in their “Adolescent Wellness” Registry, addressing the “STI Screening” measure, together with the “Chlamydia Screening in Women” measure. |
Raymonde Uy | National Association of Community Health Centers (NACHC) | ||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Accommodation | Provides information or details regarding modifications, tools, technologies, and/or other supports needed in order to address any barriers to care that an individual living with a disability(ies) may need in order to improve their care and life with a diagnosis. |
Grace Cordovano | Enlightening Results | ||
| Level 2 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Criticality | Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance. | Sandi Mitchell | J P Systems, Inc. | ||
| Level 2 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedure Status | The status of the procedure (e.g., planned, completed). |
Maria Michaels | CDC | ||
| Level 2 | Healthcare Information Attributes | Contextual information that provides supporting details for healthcare data. |
Report Date | The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.), completes collection of data for the report. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| 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) | |
| Level 2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI | LOINC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 2 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Device used | Devices are an identifiable grouping of mobility devices (i.e., wheelchairs), implantable devices (i.e., pace makers), or other wearable devices (i.e. compression socks or venous foot pump) with significant impact on patient functionality and health. The QDM v5.5 notes that “Device represents an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.” |
SNOMED CT (Frailty Device, value set OID: 2.16.840.1.113883.3.464.1003.118.12.1300) SNOMED CT (Intermittent Pneumatic Compression Devices (IPC), value set OID: 2.16.840.1.113883.3.117.1.7.1.214) SNOMED CT (Graduated Compression Stockings (GSC), value set OID: 2.16.840.1.113883.3.117.1.7.1.256) SNOMED CT (Venous Foot Pumps (VFP), value set OID: 2.16.840.1.113883.3.117.1.7.1.230) SNOMED CT (Cardiac Pacer, value set OID: 2.16.840.1.113883.3.526.3.1193) ICD-10-CM, SNOMED CT (Cardiac Pacer in Situ, value set OID: 2.16.840.1.113883.3.526.3.368) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Policy Number | The unique identifier for a specific insurance policy that defines a set of covered benefits and services along with other information that is necessary to administer the policy (e.g. financial obligations for both parties) |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| 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. |
Product Code | Provides a description of and supports traceability for a product |
ISBT-128 Product Description Code |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| 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. |
Unique Identifier | Provides a globally unique identifier code for an individual product. |
Medical Product of Human Origin Unique Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for healthcare. |
Coverage Period | The time frame in which the policy is in force. |
Robert C Dieterle | On behalf of the Da Vinci Project | ||
| 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. |
Source Identifier | Provides details on collections and pooled products such as donation identifier |
ISBT-128 Donation Identification Number |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| 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. |
Division | Provides details on aliquots or when a donation event involves more than one collection |
ISBT-128 Division Identifier |
Barbee Whitaker | Food and Drug Administration (FDA) Center for Biologics Evaluation and Research (CBER) | |
| Level 1 | Cancer Care | NCI Patient Reported Outcomes (PRO)-Common Terminology for Criteria for Adverse Events (CTCAE) | PRO-CTCAE (NCI Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events) was developed to evaluate symptomatic toxicities by self-report in adults, adolescents and children participating in cancer clinical trials. It is designed to be utilized in comparison to the Common Terminology Criteria for Adverse Events (CTCAE), the standard lexicon for adverse event reporting in cancer trials. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | ||
| Level 1 | Exposure/Contact Information | Exposure/Contact Source/Target Participant | The source or target of the exposure or contact. Could be person, animal, or location. Either the patient's contact with an entity (person, animal, or substance) or presence at a location where exposure to an agent could have occurred or the patient's contact with an entity (person, animal, or substance) or presence at a location where transmission from the patient could have occurred. | HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: US Public Health Exposure Contact Information profile (Observation.component) HL7 CDA: Exposure/Contact Information Observation template (observation/participant) |
Laura Conn | |||
| Level 1 | Work Information | Combat Zone Period | This data element is the self-reported date range(s) when a person worked in what is considered a combat zone. Both civilian workers, such as Department of Defense contractors, and military service members could have worked in combat zones. |
An information model of the Patient Work data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation. Logical Observation Identifiers Names and Codes (LOINC; https://loinc.org/) codes are available for each Patient Work Data Element, including Employment Status. The ODH code set (https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.327) provides a value set for Employment Status as well as other Patient Work Data Elements (https://phinvads.cdc.gov/vads/SearchValueSets_search.action?searchOptions.searchText=ODH). The PHIN VADS ODH Hot Topics section provides downloadable files with Preferred Concept Names and Easy Read Descriptions for Employment Status values (https://phinvads.cdc.gov/vads/SearchVocab.action). Interoperability standard formats for all of the Patient Work Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References: HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/ HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516 . Chapter 2C, Tables, Tables 0954-0959 provide the Patient Work Data Element component value sets. Chapter 3, Patient Administration, sections 3.4.15 and 3.4.18 describe the Patient Work Data Elements Employment Status and Combat Zone Period as Occupational Health (OH) segments; Retirement Date is included in the PD-1 segment. |
Genevieve Luensman | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health | ||
| Level 1 | 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. |
Promise Preference (PROPr) Utility Score | PROPr is a score for the PROMIS measurement system. PROPr combines scores from 7 PROMIS domains into a single preference-based score (also called a health utility score). This score captures the preferences of the general adult US population. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Marital Status | Patient marital status at the time of documentation. |
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 |
Maria Michaels | CDC |