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 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Supervising Physician NPI | The National Provider Identifier assigned to the Supervising Physician for the admission |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Supervising Physician Name | The name of the Supervising Physician for the admission |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Service Facility Address | The address of the facility where the service occurred. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Follow-Up | Follow-up after interventions will assess the efficacy of different treatment modalities as well as potential post-treatment complications that can help inform clinical decision making. |
ICD-10 and SNOMED CT ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California, San Francisco Breast Cancer Center | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Complications | The data element specifically documents complications that result from different modalities of therapy. There is currently no way of collecting this information and thus we miss the opportunity for quality improvement and true informed consent. High level complications should be recorded and ascribed to the modality (ies) of therapy. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Claim Operating Surgeon Name | The name of the operating surgeon. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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. |
Sleep Log /Diary | A patient with a sleep problem will often be asked to keep a Sleep Log or Diary , record of sleep behaviors usually including sleep time. wake time, sleep duration, frequency and duration of sleep interruptions, medications, perceived sleep quality, caffeine intake, etc. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| Level 0 | Goals and Preferences | Desired state to be achieved by a person or a person’s elections to guide care. |
Religious & Spiritual Preferences | Defines an individual's religious or spiritual preferences which helps to support whole-person care in the in-patient and out-patient settings as well as in the palliative and end-of-life care settings. |
Grace Cordovano | Enlightening Results | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Country of Usual Residence | The patient’s usual country of residence |
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: Country of Residence profile HL7 CDA: Country of Residence template |
Laura Conn | ||
| Level 0 | Nutrition and Diet | Oral Diet Nutrient Modifiers | Nutrients that are increased or decreased in conjunction with the oral diet type as part of a therapeutic diet. For example, “decreased sodium” or “increased protein”. | HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Start/End Date | The start and end date of a medication order. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Mitigating action | Ameliorating actions taken after the adverse event occurred in order to reduce the extent of harm | HL7.org FHIR R4 v4.0 |
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. |
Sleep Quality | Describes patient sefl-perception of overall sleep quality. Sleep quality can affect general health and can be bi-directionally associated with associated with various diseases and disorders. Several instruments exist for characterizing general sleep quality including the Pittsburgh Sleep Quality Index. Buysse, D. J., Reynolds III, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| 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. |
Obstructive Sleep Apnea Screening | The recognition of Obstructive Sleep Apnea (OSA) is important in reducing the disease burden of cardiovascular disease. OSA is strongly correlated with cardiovascular disorders and management of this condition may facilitate better control of cardiovascular disorders leading to improved patient outcomes. Several OSA screening tools exist, including the STOP Questionaire and the Epworth Sleepiness Scale. Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008:108;812-21. Johns MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991; 14(6):540-5. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| 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. |
Insomnia Screening | Insomnia is a very common complaint in the general population and can contribute to a state of inadequate or mistimed sleep, which can affect general health, mental wellbeing and daytime functioning. Several screening tools exist to identify and severity of insomnia, including the Insomnia Severity Index. Insomnia is a common, treatable condition that often goes undiagnosed and can negatively affect general physical and mental health. Insomnia is very common, the American Academy of Sleep Medicine reports that approximately 30% - 40% of US adults report symptoms of insomnia at some point in a given year. Insomnia is a common, treatable condition that often goes undiagnosed and can nagatively affect general physical and mental health. Charles M. Morin, PhD, Geneviève Belleville, PhD, Lynda Bélanger, PhD, Hans Ivers, PhD, The Insomnia Severity Index: Psychometric Indicators to Detect Insomnia Cases and Evaluate Treatment Response, Sleep, Volume 34, Issue 5, 1 May 2011, Pages 601–608, https://doi.org/10.1093/sleep/34.5.601 |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Study | Research study that the subject is enrolled in | HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Contributing Factor | Contributing factors suspected to have increased the probability or severity of the adverse event |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | |
| Level 0 | Adverse Events | Unintended effects associated with clinical interventions. |
Participant(s) | Who was involved in the adverse event or the potential adverse event and what they did | HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | |
| Level 0 | Social Determinants of Health | Self-Identified Need for Contraception (SINC) | Self-Identified Need for Contraception screening tool for primary care settings. |
Self-Identified Need for Contraception (SINC) LOINC: 98076-3 |
Dr. Christine Dehlendorf | Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco | ||
| Level 0 | Nutrition and Diet | Eating/drinking assistive device | External devices that are designed, made, or adapted to assist a person with eating and/or drinking | HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC |
Becky Gradl | Academy of Nutrition and Dietetics |