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 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Medicare Patient Identifier | Medicare Beneficiary Identifiers (MBI) used to uniquely identify Medicare patients. |
MBI format specifications: https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf HL7 Identifier type value set, see MC (http://hl7.org/fhir/R4/v2/0203/index.html) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Custodian Organization Telecom | A telecom of the custodian organization. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedure Treatment Intent | The purpose of a treatment, or the desired effect or outcome resulting from the treatment. For example, a treatment may be intended to completely or partially eradicate a disease process by disrupting its underlying physiological processes, resulting in improvement in health; or a treatment may have no expectation of eradication but rather may be intended simply to delay the onset of more severe symptoms; or may be intended to prolong life without any expectation of cure. NOTE: Treatment Intent has also been submitted under the Medications data class |
SNOMED CT codes for therapeutic intent (qualifier value) |
Andre Quina | MITRE | |
| Level 0 | Newborn's Delivery Information | Apgar Score | APGAR score post-birth including scores at 1, 5 and 10 minutes. |
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 |
Craig Newman | Altarum | ||
| Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, 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 | |
| Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, 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 family, 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 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Address Use Period | This is the address start and end date. The time period is important in determining the current address versus address at diagnosis. |
Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion |
Maria Michaels | CDC | |
| Level 0 | Pregnancy Information | Number Fetal Deaths This Delivery | The number of fetal deaths in this delivery. |
LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive |
Craig Newman | Altarum | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Multiple Birth Order | If not a single birth then the order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.). |
FHIR patient extension: birthplace FHIR patient address.period |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 0 | Referral | Referral coverage | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Referral | Referral code | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Referral | Referral requestor | The individual who initiated the request and has responsibility for its activation. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Medical Record Number | The unique identifier assigned by the provider to reference a single patient |
Structural standards exist for the capture and exchange of MRNs and are part of all EHRs and standard transaction. However, there is no global assignment of an identifier to an individual patient. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article 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 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| 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. |
Right eye Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79892-6 |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
Kerry Goetz | NIH/NEI | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescribed Dose | Indicates the amount of medication per dose that is to be used by the patient. |
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 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator measured plateau pressure | The measured plateau pressure 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 | 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. |
Left eye Intraocular pressure | Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79893-4 |
LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4 |
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 left eye | Same as above |
LOINC |
Kerry Goetz | NIH/NEI |