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 | Work Information | Job Employer Phone | Phone number of the individual's employer. | Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| Level 0 | Work Information | Job Title | Name of the job position held by an individual. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | |||
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity corrected left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Refraction | A refraction test is what the doctor uses to get your eyeglasses prescription. You look at a chart, usually 20 feet away, or in a mirror that makes things look like they’re 20 feet away. You’ll look through a tool called a phoropter. It lets the doctor move lenses of different strengths in front of your eyes. The test also helps your doctor spot presbyopia, hyperopia, myopia, and astigmatism. Source: WebMD Glossary of Eye Tests and Exams LOINC Panel 79895-9 |
LOINC Panel 79895-9 Subjective refraction measurements panel |
Kerry Goetz | NIH/NEI | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual acuity logMAR right eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI | |
| 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 | 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. |
Medical Device Name | The name of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| 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. |
Depression Screening | Assessment of clinical depression using standardized tools. |
LOINC |
Grace Glennon, on behalf of NCQA | NCQA | |
| 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. |
Pain Assessment | An assessment of a person’s pain, which could include assessment of acute and chronic pain using standardized assessment tools. Assessments of pain include but not limited to pain severity, interference of pain on activity, and pain impact on mood or sleep using unidimensional or multidimensional assessment tools. | LOINC and SNOMED CT |
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| Level 0 | Pregnancy Information | Number of Prenatal Visits | The total number of prenatal visits for the mother. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Newborn's Delivery Information | Birth Weight | The weight of the infant/fetus at birth/delivery. |
LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score |
TICIA Louise GERBER | Health Level Seven International | ||
| Level 0 | Newborn's Delivery Information | Pregnancy Outcome | The result of the subject’s delivery, such as live birth or not a live birth. |
LOINC codes exist for each of the proposed data elements: 73766-8: Place where birth occurred [US Standard Certificate of Live Birth] 8339-4 - Birth weight Measured |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Reason for the Encounter | Reason the encounter takes place, expressed as a code. |
Encounter Status: FHIR Encounter Status: http://hl7.org/fhir/ValueSet/encounter-status Classification of Encounter: V3 Value SetActEncounterCode: http://hl7.org/fhir/ValueSet/v3-ActEncounterCode Encounter Type: FHIR Encounter type: http://www.ama-assn.org/go/cpt Encounter participant type: FHIR Participant type: http://hl7.org/fhir/ValueSet/encounter-participant-type Reason for the encounter: FHIR Encounter Reason Codes: http://hl7.org/fhir/ValueSet/encounter-reason Hospital encounter discharge disposition: FHIR Discharge disposition: http://hl7.org/fhir/ValueSet/encounter-discharge-disposition Expected source(s) of payment for this encounter: FHIR Coverage Type and Self-Pay Codes: http://hl7.org/fhir/R4/valueset-coverage-type.html Encounter chief complaint: FHIR DiagnosisRole: http://hl7.org/fhir/R4/valueset-diagnosis-role.html |
Maria Michaels | CDC | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Medical Device Use | The use of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Ventilator Mode | The mode of mechanical ventilation if the patient is receiving mechanical ventilation. Could refer to LOINV 20124-4 for options. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Ventilator pressure support | The pressure support above PEEP if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Ventilator set respiratory rate | The set respiratory rate if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
Ventilator set tidal volume | The tidal volume set on the ventilator if the patient is receiving mechanical ventilation. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| 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. |
Patient Communication Status | The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange. The PACIO community strongly recommends creating an element specifically for patient communication status under the USCDI category of Health Status Assessments. The most current version of USCDI does not include any data elements addressing communication. Communication is the active process of exchanging information and ideas. Communication involves both understanding and expression. Forms of expression may include personalized movements, gestures, objects, vocalizations, verbalizations, signs, pictures, symbols, printed words, and output from augmentative and alternative (AAC) devices (2). When an individual communicates effectively, they are able to express needs, wants, feelings, and preferences that others can understand and can accurately receive messages from others. A person’s ability to comprehend and express information plays a critical role in medical decision making, sharing wishes with caregivers and practitioners, navigating the health care system, patient safety and satisfaction, decrease diagnostic errors, and shapes the journey and interactions when traveling between different health care institutions where one relies heavily on patient’s communication skills (4). The PACIO community encourages the ONC/USCDI to incorporate communication as a data element under the proposed USCDI V4 data class of Health Status Assessments. Assessment or screening the presence of communication deficits and need for special accommodations should be considered under this data element. Effective communication not only improves a patient’s quality of life and independence but improves health outcomes, reduces health care costs, and eases administrative burden. Communication can take many forms. Examples include but are not limited to the person’s ability to understand spoken or written language, person’s ability to express needs, wants and wishes through spoken or written language, person’s ability to produce intelligible speech, use of sign language, use of Augmentative and Alternative Communication (AAC), use of communication devices, or strategies to be used by the communication partner. |
LOINC and SNOMED_CT vocabularies |
Howard Capon | The PACIO Project |