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 1 | Genomics | Variant Type | The data representing the type of genetic variation. Some examples of variant types include DNA, protein, chromosome. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Security Label | Security Label Confidentiality Tag | A Confidentiality tag is the 1..1 component of a Security Label that conforms to the HL7 Healthcare Privacy and Security Classification System (HCS), Release 1 (HCS) syntax to represent the level of protection prescribed by a policy governing the information to which a label is assigned. The HL7 Healthcare Privacy and Security Classification System (HCS), Release 1 (HCS) can be found at: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=345 HL7 recommends creating a value set of Confidentiality codes specific to priority US policies as discussed in the HL7 Cross-Paradigm US Regulatory Security Labeling Implementation Guide, which is under development and can be found at: https://build.fhir.org/ig/HL7/us-security-label-regs/branches/master/index.html For v3 HL7 Confidentiality Codes, see the Confidentiality value set at: https://build.fhir.org/ig/HL7/UTG/ValueSet-v2-0952.html For background on use of Confidentiality codes, see https://confluence.hl7.org/display/SEC/Use+of+Confidentiality+Codes+in+HL7+Security+Labeling . For use of Confidentiality codes in CDA, see HL7 Implementation Guide: Data Segmentation for Privacy (DS4P), Release 1. For use of Confidentiality codes in FHIR see http://hl7.org/fhir/uv/security-label-ds4p/2020May/background.html For use of Confidentiality codes in HL7 Version 2, see v2.9 ARV Segment. |
HL7 v3 code systems and value sets, and HL7 standards listed in the Data Elements above, and discussed in the use cases. All be the Cross Paradigm for US Regulatory Security Labeling, FHIR US Regulatory Security Labeling IG, and the FHIR DS4P IG are normative. |
TICIA Louise GERBER | Health Level Seven International | ||
| Level 1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Patient | The person who received the administered medication. While seemingly self-evident as a part of an administration record, the requirement of the patient being linked to the drug administered is critical (assuming Medication Administrations become part of USCDI |
In FHIR R4, https://www.hl7.org/fhir/medicationadministration-definitions.html#Medi… |
Scott Gordon | Food and Drug Administration | |
| Level 1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pain Severity | This element is used to describe how intense or severe the sensation of pain is on a 1-10 scale. |
LOINC: 38208-5 Pain severity – Reported |
Dr Susan A Matney | Intermountain Healthcare | |
| 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 | Exposure/Contact Information | Exposure/Contact Type | The type of exposure/contact (environmental, activity, event, location, person, animal, etc.) to an agent. | 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 | Special Alerts for Care Handoffs | Results LOINC | All pending results and contact information for how to obtain |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| 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. |
Terminal Illness Status | Recommended to have element for Terminal Illness Status in this Data Class in USCDI V3. This is a matter of interest to Next of Kin/Related Parties and of high value to Care Team (needed for revised Care Plan) and would immensely help with timely and seamless Transition and Coordination of Care between different settings and care givers. |
Terminal illness (Code 300936002) SNOMED code. https://www.hipaaspace.com/medical_billing/coding/snomed/300936002 https://www.findacode.com/snomed/162607003--terminal-illness-early-stag… https://build.fhir.org/ig/cqframework/opioid-cds-r4/ValueSet-limited-li… |
Dave Shekhar | ||
| Level 1 | Security Label | Security Label Purpose of Use (POU) Tag | A POU tag is the 0..* component of a Security Label that conforms to follows the HL7 Healthcare Privacy and Security Classification System (HCS), Release 1 syntax to indicate the circumstances under which an authorized recipient is permitted to perform an activity such as create, collect, access, use, or disclose. For HL7 POU codes, see POU value set at: https://build.fhir.org/ig/HL7/UTG/ValueSet-v3-PurposeOfUse.html We recommend creating a value set of POU codes to value the POU tag, which are specific to priority US policies as discussed in the HL7 Cross-Paradigm US Regulatory Security Labeling Implementation Guide, which is under development. |
HL7 v3 code systems and value sets, and HL7 standards listed in the Data Elements above, and discussed in the use cases. All be the Cross Paradigm for US Regulatory Security Labeling, FHIR US Regulatory Security Labeling IG, and the FHIR DS4P IG are normative. |
TICIA Louise GERBER | Health Level Seven International | ||
| Level 1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Module | The medication module is concerned with resources and functionality in 3 main domains: (1) the ordering, dispensing, administration of medications and recording statements of medication use, (2) Recording of Immunizations given (or not given), evaluation of given immunizations and recommendations for an individual patient at a point in time, and (3) The creation or querying for medications as part of drug information or drug knowledge. https://www.hl7.org/fhir/medications-module.html |
RxNorm and SNOMED CT |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 1 | Exposure/Contact Information | Exposure/Contact Date | The date or period on which the possible exposure/contact 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 | Exposure/Contact Information | Exposure/Contact agent | The possible agent of concern in the exposure/contact. | 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 | Exposure/Contact Information | Exposure/Contact Direction | Whether the direction of exposure/contact is acquisition (patient is the target and another person, animal, location, etc. is the source) or transmission (patient is the source and another person, animal, location, etc. is the target). | 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 | 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Airway Management | Patient history and assessments performed by healthcare providers which are used to identify airway management techniques used and potential complications. These elements are important for any patients undergoing airway management, whether in the emergency department, in the intensive care unit, or in the operating room for elective or emergent surgical procedures with anesthesia. |
Difficult tracheal intubation: Difficult mask ventilation: Mallampati scores: Video intubation: (glidescope) Intubation techniques: Difficult supraglottic airway ventilation |
Matthew Popovich | American Society of Anesthesiologists | |
| Level 1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Maternal Social Determinants of Health Note | The Maternal Social Determinants of Health Note supports the aggregation of significant events, social problems and related health concerns, and plans of care derived from the visits over the course of a maternal care episode. It is a summary of the most critical information maternal care providers capture and share regarding the status of a maternal patient's social issues. The information is aggregated data from which the patient’s interactions with healthcare and social services providers are captured. |
SNOMED CT LOINC ICD10 ICD9 CM ICD10CM, SNOMEDCT |
Andrea Fourquet | IHE USA | |
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory results: date and timestamps | Date and timestamps associated with the completion of laboratory results, that are meta data associated with laboratory results |
LOINC codes for labs—date and timestamps collected in standard format |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Cause of Death | Cause of death information includes the sequence of events leading to death as well as other conditions significantly contributing to death. The underlying cause of death may be different than the terminal condition. This may include summary of death note, and/or death information that may be captured within the discharge summary note or other cause of death documentation within the clinical notes section. |
LOINC: Summary of death note: 47046-8: https://loinc.org/47046-8/ Physician Summary of death note: 83796-3: https://loinc.org/83796-3/ Nurse Summary of death note: 84273-2: https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Supporting Links: PHINVADS Value Set: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3593 |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication List Type | Codification of the type of medication list (e.g. Active medication list, Reconciled medication list, Discharged medication list, Discontinued (Inactive) medication list, Patient generated medication list (Different nuance, needs to be reviewed by a clinician before it can be entered as an active medication list), Medications that are private and need patient consent to share, Medication administration list, Medication administration list for public health and CDC reporting (e.g., for COVID, Antibiotics for Antibiotic Stewardship), Discharged medication list (Feeds the discharge summary that contains the Discharged medication list and when transferring within a hospital from one level of care to another (intersystem), a transfer medication list is used for MR). |
LOINC |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Report Submission Date/Time | The date and time at which the EHR system sends the report. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) |