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 | 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 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Social Security Number | Records patient’s social security number. |
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 | |
| Level 1 | Work Information | Retirement Date | Retirement Date is a self-reported date (at least year) that a person considers themselves to have ‘retired’. A person can have more than one Retirement Date. A person can be both employed and retired, so these data are independent of one another. |
An information model of the Work Information 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) codes are available for each Work Information Data Element and each component of the data elements, including Retirement Date (https://loinc.org/). Interoperability standard formats for all of the Work Information 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 3, Patient Administration: Retirement Date is included in the PD-1 segment. |
Genevieve Luensman PhD | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH) | ||
| 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 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient's Primary Care Provider | Patient's nominated care provider. [Knowing this at the patient level can help answer the question at the encounter level whether the pt. was seen by PCP.] |
Medicare Beneficiary Identifiers (MBIs) |
Nedra Garrett | Centers for Disease Control and Prevention | |
| 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. |
Two-item PROMIS®️ global physical and mental health scales | Two-item PROMIS®️ global physical and mental health scales: Global health items provide synoptic information that can be utilized as predictive indictors of health care utilization and mortality. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| 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 | 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 | 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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Instrument Unique Identifier | Uniquely identifies the type of instrument that was used in conjunction with the Test kit (at minimum by using instrument name and manufacturer (similar to the make and model of a car)) to obtain the Test Result Value. When a testkit is used on an instrument it is the combination of kit and instrument, that qualify the Performed Test. |
Riki Merrick | Association of Public Health Laboratories | ||
| Level 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Variation in Sex Characteristics | Were you born with a variation in your physical sex characteristics? (This is sometimes called being intersex or having a Difference in Sex Development, or DSD.) |
LOINC has an intersex response option, 99502-7, for Recorded sex or gender. LOINC has an intersex response option. We do not endorse the way LOINC conceptualizes intersex (as corresponding to an X response to a sex or gender question). |
Sean Cahill | Fenway 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. |
PROMIS (Patient-Reported Outcomes Measurement Information System) survey score result | Patient-Reported Outcomes Measurement Information System (PROMIS) program created new paradigms for how clinical research information is collected, used, and reported. PROMIS addressed a need in the clinical research community for a rigorously tested patient reported outcome (PRO) measurement tool that uses recent advances in information technology, psychometrics, and qualitative, cognitive, and health survey research to measure PROs such as pain, fatigue, physical functioning, emotional distress, and social role participation that have a major impact on quality-of-life across a variety of chronic diseases. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | Facility Information | Physical place of available services or resources. |
Facility GPS Coordinates | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry | ||
| 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 | Patient Summary and Plan | Information that guides treatment of the patient and recommendations for future treatment. |
Treatment Change | Treatment Change documents the reason for changes to the plan of treatment plan. The options for this data element are, for example: no change (continue treatment), planned change, no response to treatment, adverse reaction, patient request for alternative treatment. The first option (no change in treatment plan) can document a review of the treatment plan that did not require in a change of treatment. |
LOINC, SNOMED-CT, and FHIR see: https://search.loinc.org/searchLOINC/search.zul?query=functional+status http://hl7.org/fhir/us/mcode/ https://browser.ihtsdotools.org/?perspective=full&conceptId1=273472005&edition=MAIN/2020-07-31&release=&languages=en |
Andre Quina | MITRE | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Device Settings | Patient-specific settings associated with a device. |
Device Type: SNOMED (Implanted port-central lines and tunneled hemodialysis catheters; Non-implantable devices would include ventilators, temporary central lines, urinary catheters) Location of Device Initiation: HSLOC code system (https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/hsloc.html) Device Settings: LOINC (fraction of inspired oxygen, pressure support, positive end-expiratory pressure, ventilator mode, tidal volume delivered, frequency/respiratory rate setting - delivered by the ventilator) Device Observations / Measurements: LOINC (peak pressure, plateau pressure, spontaneous tidal volume, respiratory rate - spontaneous that the patient breaths) Device Route: type of airway (nasal cannula, facemask, endotracheal tube, tracheostomy) - delivery, approach - Feedback requested Device Status: related value sets: http://hl7.org/fhir/R4/valueset-device-status.html (active, inactive) or http://hl7.org/fhir/ValueSet/metric-operational-status (on, off, standby) - weaning trial - may be a property of the Procedure - Feedback requested |
Sheila Abner | CDC/NHSN | |
| 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) |