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 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.

Endoscopy

Narrative clinical assessment of the Endoscopy results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
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

Narrative clinical assessment of the Visual Acuity evaluation.

Please see suggestions from attached Excel document

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 Mike Schmidt HiQ Services, LLC
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 Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Physical Exam

Narrative clinical assessment of the Physical Exam results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Adverse Events

Unintended effects associated with clinical interventions.

Outcome Status Adverse Event Status – i.e. in-progress, completed, entered-in-error, unknown

HL7.org FHIR R4 v4.0

Sandi Mitchell J P Systems, Inc.
Level 0 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

Custodian

The custodian is the organization that is in charge of maintaining and is entrusted with the care of the document.

Sarah Gaunt The Association of Public Health Laboratories (APHL)
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
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
SNOMED CT: https://www.snomed.org/

Kevin Jung University of California San Francisco Breast Care Center
Level 0 Vital Signs

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Individual Administering Vital Signs

Identify the role of the individual taking the vital signs, differentiating between inputs that are from a care team member, patient or family/caregiver, as separate from an automated device or home monitoring system.

For care team members: Examples include but are not limited to National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID).

For FDA approved devices: FDA Unique Device Identification (UDI) System

Tayler Williams American Medical Informatics Association (AMIA)
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.

Physical Activity – Minutes/Day

On those days that the patient engages in moderate to vigorous exercise, how many minutes, on average, do they exercise?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

Laurie P. Whitsel American Heart Association/Physical Activity Alliance
Level 0 Adverse Events

Unintended effects associated with clinical interventions.

Actuality Did the event (harm) occur or is there potential for harm – ie. Actual, potential

HL7.org FHIR R4 v4.0

Sandi Mitchell J P Systems, Inc.
Level 0 Adverse Events

Unintended effects associated with clinical interventions.

Category Type of harm – wrong patient, medication mishap, wrong body site, etc.

HL7.org FHIR R4 v4.0

Sandi Mitchell J P Systems, Inc.
Level 0 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Specimen Received Date/time

Date (and optionally time) when specimen was received by the testing laboratory

V2 = SPM-18 (Specimen Received Date/Time) https://www.hl7.eu/refactored/segSPM#248 and also in OBR-14 (Specimen Received Date/Time) = https://www.hl7.eu/refactored/segOBR.html#248 in versions before SPM segment was added, in FHIR = https://build.fhir.org/specimen-definitions.html#Specimen.receivedTime

Riki Merrick APHL
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.

Physical Activity – Minutes/week

For an average week in the last 30 days, how many minutes per week did the patient engage in moderate to vigorous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

Laurie P. Whitsel American Heart Association/Physical Activity Alliance
Level 0 Medical Devices

Instrument, machine, appliance, implant, software, or similar device intended to be used for a medical purpose.

Measured ventilator peak inspiratory pressure

Measured peak inspiratory pressure if the patient is receiving mechanical ventilation

Airway type LOINC LL5542-7
PEEP LOINC 20077-4
Pressure support LOINC 20079-0
Plateau Pressure LOINC 76259-1
Tidal Volume LOINC 76221-1
Respiratory Rate LOINC 33438-3

Ali Abbasi MD- on behalf of the I-SPY COVID investigators I-SPY COVID Trial Investigators
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Neuropsychological Testing

Narrative clinical assessment of the Neuropsychological Testing results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Goals and Preferences

Desired state to be achieved by a person or a person’s elections to guide care.

Patient Goal Category

Domain of the stated patient goal.
Examples of goal categories include housing, physical function, behavioral, and social & role functioning.

HL7 Terminology: Goal Category.

NCQA is also actively working with the HL7 Patient Goals work group to update the HL7 terminology for “goal category” to include additional patient goal categories aligned to our work.

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.

Physical Activity – Days/week

For an average week in the last 30 days, how many days per week did the patient engage in moderate to vigorous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

Laurie P. Whitsel American Heart Association/Physical Activity Alliance
Level 0 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

Rurality

Individual's self-identification as living in a rural area. Rurality is recognized in public health science as a significant indicator of adverse rates of morbidity and morality; this is sometimes called the 'rural health penalty'. Rurality is a complex phenomenon that researchers treat fluidly, with changing definition: https://www.sciencedirect.com/science/article/abs/pii/S0743016721000437 This failure of research to confirm a settled defintion should not constrain from asking the individual's self-identification, anymore than the failure of research to confirm a settled definition of sex or gender should constrain from asking the individual's self-identification of sex or gender.

edward strickler member and past chair, ethics, american public health association
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.

Mental Status Evaluation

Narrative clinical assessment of the Mental Status Evaluation.

Please see suggestions from attached Excel document

Melissa Ayres SSA