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 Work Classification | A coded term that characterizes the arrangement between the employer and the person in a job, such as 'paid work, self-employed' or 'voluntary work in disaster/emergency response', as reported by the person. |
PHVS_WorkClassification_ODH |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Job Work Schedule | A coded term for the typical arrangement of working hours for a job, as reported by the person. |
Value Set - Work Schedule (ODH) |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Industry | A self-reported term that identifies the kind of business, i.e., primary business activity, in which a person has worked for the longest time while in their Usual Occupation. For a military position, this is the self-reported branch of service. If an appropriate term is not available (e.g., a new kind of business), then a text entry is used. | Occupational Data for Health (Value Set - Industry NAICS Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7900 Industry CDC Census 2010 http://hl7.org/fhir/us/odh/ValueSet-codesystem-industry-cdc-census-2010.html |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Occupation | A self-reported, coded term for the type of work (paid or unpaid) done by a person for the longest amount of time during his or her life, not including voluntary work (done by choice for the benefit of others without compensation). |
Occupational Data for Health (Value Set - Occupation ONETSOC Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7901 Occupation CDC Census 2010 https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7186 |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Occupation Duration | The self-reported total of all periods of time (in years) a person has spent in their Usual Occupation as of the date recorded, not including intermittent period(s) when the person was not working in that occupation. It is recorded as an integer to one decimal place. | Nedra Garrett | CDC | |||
| 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 | Adverse Events | Unintended effects associated with clinical interventions. Exclusions: This data class does not include patient safety analyses, internal risk management documentation, or patient safety work product as defined under the Patient Safety and Quality Improvement Act of 2005 (42 U.S.C. 299b 21 et seq.) and implementing regulations (42 CFR part 3). It is not intended to define data elements for the exchange of Patient Safety Organization (PSO) investigations, safety reviews, or facility level reporting activities. |
Adverse Event Severity | Degree to which an an unfavorable or unintended disease, sign, or symptom that is temporally associated with the use of a medical treatment or procedure, affects the health and wellbeing of the subject. Usage Note: Adverse event may or may not be directly caused by the medical treatment or procedure. Severity may be represented by several scales or descriptions. | The use of NCI CTCAE and SNOMED CT. The severity value sets of the adverse event are part of an existing FHIR CodeSystem: AdverseEventSeverity |
Vulcan | Vulcan | |
| Level 0 | Work Information | Usual Occupation Start Date | The self-reported year that a person started working in their Usual Occupation. | Nedra Garrett | CDC | |||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Knowledge | The MedicationKnowledge resource is draft and is included for comment purposes. This resource represents information about a medication, for example, details about the medication including interactions, contraindications, cost, regulatory status, administration guidelines, etc. https://www.hl7.org/fhir/medicationknowledge.html |
RxNorm and SNOMED CT |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescription Patient | The person who is the intended recipient of the medication. While seemingly self-evident as a part of an prescription record, the requirement of the patient being linked to the drug administered is critical | In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.subject |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Therapeutic Medication Response | Represents a therapeutic response (as opposed to an undesired reaction) to the administration of a medication. |
HL7 FHIR: Therapeutic Medication Response extension HL7 CDA: Therapeutic Medication Response observation LOINC: 67540-5 "Response to medication" VSAC Value Set: Therapeutic Response to Medication |
Laura Conn | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescription Do-Not-Perform | Do-not-perform is an additional Boolean element in HL7 FHIR R4 Medication Request representing the provider’s intent that the prescription NOT be carried forward. If it is assumed that Status will be updated based on this command (ie, status will be changed to “cancelled” then this may be redundant. Alternative is an additional Status of “cancelled-by-provider” |
In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.status |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Medical Devices | Instrument, apparatus, machine, equipment, implant, software, hardware, or related component or accessory intended to diagnose, treat, cure, mitigate, or prevent disease, or to affect the structure or function of the body. |
Status Date | The date associated with the corresponding implantable device status. | standard date formats |
TICIA Louise GERBER | Health Level Seven International | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Reported Medication (unique) | “Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record.” (from FHIR R4 MedicationRequest.reported[x]). This would clearly identify a medication that only exists in the data system not as part of any direct data for an original prescription (within the same EHR or across an EHR network, etc) but, instead, via descriptive communication or narrative (verbal, written, etc) by a relevant person (the patient, family, a caregiver, another physician, etc.) This may either be represented as a simple Boolean choice or, additionally, include information of the person and/or nature of the reporting. Additionally, some standards and system implementations provide more than one location for this type of information – and different options are used by different implementations resulting in highly non-standardized usage of this critical information. Proposal is that this information is captured ONLY in one way, universally across systems. |
In FHIR R4, MedicationRequest.reported[x] (https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.reported_x_) supplied either a boolean or Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) In FHIR R4 MedicationStatement - FHIR v4.0.1 (https://www.hl7.org/fhir/medicationstatement.html) which is still sometimes used to represent reported medications, a number of key terminologies are utilized |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Nutrition and Diet | Oral Diet Fluid Consistency | The required consistency of fluids and liquids provided to improve safety for patients with swallowing difficulties. For example, “moderately thick” or “thin”. The ISDDI Framework (https://iddsi.org/Framework) for drinks is recommended as the terminology for this data element. |
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 | Nutrition and Diet | Oral Diet Texture Modifiers | Texture modifications to indicate how to alter the texture of foods to improve safety for patients with swallowing difficulties. For example, “pureed” or “soft & bite-sized”. The ISDDI Framework (https://iddsi.org/Framework) for foods is recommended as the terminology for this data element. | 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 | Travel Information | Purpose of Travel | Purpose of travel (business, tourism, etc.) |
HL7 FHIR: US Public Health Travel History profile (Observation.component) HL7 CDA: Purpose of Travel Observation template SNOMED: 280147009 "Travel Purpose" PHIN VADS Value Set: PHVS_TravelPurpose_CDC |
Nedra Garrett | CDC | ||
| 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 | Pregnancy Information | Pregnancy Intention Screening | Screening patient for their desire to become pregnant in the next 12 months in order to determine which reproductive health services may be relevant to offer the patient in that encounter. |
Pregnancy Intention Screening Question: Pregnancy intention in the next year - Reported SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22 |
Emily Decker | Upstream USA | ||
| 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 |