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 | Pregnancy Information | Gestational Age | "The estimated gestational age (in weeks, or weeks and fraction of week) of the pregnancy at the time of the health care encounter (in contrast to the gestational age at birth), beginning from the time of fertilization. Needs to be correlated with the date the gestational age was documented. Gestational age (written with both weeks and days) is calculated using the best obstetrical estimated delivery date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date))/ 7" |
https://www.hl7.org/implement/standards/product_brief.cfm?product_id=494 |
Nedra Garrett | Centers for Disease Control and Prevention | ||
| 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. |
ECOG | The Eastern Cooperative Oncology Group (ECOG) Performance Status represents the patient's functional status and is used to determine how a disease impacts a patient’s daily living abilities and their overall ability to tolerate therapies in serious illness, specifically for chemotherapy. |
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 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Service Request | 12.18 Resource ServiceRequest ServiceRequest represents an order or proposal or plan, as distinguished by ServiceRequest.intent to perform a diagnostic or other service on or for a patient. ServiceRequest represents a proposal or plan or order for a service to be performed that would result in a Procedure or DiagnosticReport, which in turn may reference one or more Observations, which summarize the performance of the procedures and associated documentation such as observations, images, findings that are relevant to the treatment/management of the subject. This resource may be used to share relevant information required to support a referral or a transfer of care request from one practitioner or organization to another when a patient is required to be referred to another provider for a consultation /second opinion and/or for short term or longer term management of one or more health issues or problems. |
Philip Lieberman | Analog Informatics Corporation | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Slot | A slot of time on a schedule that may be available for booking appointments. |
Philip Lieberman | Analog Informatics Corporation | ||
| Level 0 | Pregnancy Information | Estimated Date of Delivery | The expected date of delivery (i.e. the due date). |
LOINC codes exist for each of the proposed data elements: 8665-2 - Last menstrual period start date 11778-8 - Delivery date Estimated 56077-1 - Body weight --pre current pregnancy |
Craig Newman | Altarum | ||
| 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. |
Domestic Life/ Instrumental Activities of Daily Living (IADLs) | This data element carries information on Domestic Life/IADL that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Domestic Life/IADL is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as preparing simple meals, cleaning living area, shopping, etc.. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Domestic Life/IADL concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Domestic Life/IADL data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as make light hot meal, light daily housework, light shopping using assessments coded with LOINC. |
LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966 |
Michelle Dougherty | Submitted on behalf of the CMS Data Element Library (DEL) Health IT Workgroup | |
| Level 0 | Goals | Desired state to be achieved by a patient. |
Outcome Reference | Details of what's changed (or not changed). |
HL7 FHIR |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Income | Patient income level |
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| Level 0 | Goals | Desired state to be achieved by a patient. |
Outcome Code | Identifies the change (or lack of change) at the point when the status of the goal is assessed |
HL7 FHIR |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Medical Devices | Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose. |
DME Orders | Medically necessary equipment (and the corresponding order) that a physician prescribes for use in a patient’s home, including wheelchairs, walkers, and hospital beds. |
The Centers for Medicare & Medicaid Services (CMS) annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions to reflect codes that are either added or discontinued (deleted) each year. The jurisdiction list is an Excel file and is available at https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center |
Matt Reid | American Medical Association | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Reason Reference | Reference to a condition that is the reason for the medication administration. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose Units | The units of measure associated with the amount of medication given at one administration event |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Dose | The amount of the medication given at one administration event. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Code | A code (or set of codes) that specify the medication that was administered. |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Date Medication Administered | A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true). |
Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org |
Maria Michaels | CDC | |
| Level 0 | Substance Use | Tobacco/Nicotine Product Type | Tobacco/Nicotine containing products used as a method of consumption. Question Prompt: What type(s) of tobacco products? Permissible Values: o Cigarette (SNOMED: 66562002) A thin cylinder of ground or shredded tobacco that is wrapped in paper, lit, and smoked. o Cigar (SNOMED: 26663004) A tube of tobacco that is thicker than a cigarette, wrapped in tobacco leaf, lit, and smoked. Cigars include regular cigars, cigarillos, and little filtered cigars. o Pipe (SNOMED: 84498003) A tube with a small bowl at one end that is filled with tobacco, lit, and smoked. o Smokeless (SNOMED: TBD) This delivery mechanism does not require smoking and includes, Chewing tobacco, Dip, Snuff, Dissolvable and Snus. o E-Cigarette/Vape (SNOMED: TBD) An electronic cigarette is a vaporizer device that simulates smoking by providing some of the aspects of smoking that includes nicotine but without combusting tobacco. Also called E-Cigs, Personal Vaporizer. o Unknown-(SNOMED: TBD) An individual for whose tobacco product use is unknown. |
There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use. |
Anita walden | HL7 Common Clinical Registry Framework project | ||
| Level 0 | Substance Use | Tobacco/Nicotine Use Start Age | The age of the individual when they started nicotine consumption/use. Question Prompt: Age started nicotine consumption/use. |
There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use. |
Anita walden | HL7 Common Clinical Registry Framework project | ||
| Level 0 | Appointment | Schedule | A container for slots of time that may be available for booking appointments. |
Philip Lieberman | Analog Informatics Corporation | |||
| Level 0 | Social Determinants of Health | SDOH Protective Factors | Social determinants of health-related characteristics or strengths of individuals, families that act to mitigate risks and promote positive well-being and healthy development |
SNOMED CT |
Sarah Candace DeSilvey | Gravity Project | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter Participant | 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 |