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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administered Performer | Indicates who or what performed the medication administration and how they were involved. |
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. |
Unique Mobile Health Application Identifier (UMHAI) | This is a unique identifier that uniquely identifies mobile health application instance as installed on a mobile device. Related data elements would include Application name, App Builder, version, build number, hosting device, unique identifiers [similar to a Vehicle Identification Number (VIN) used to track and identify individual vehicle]. Unique Mobile Health Application Identifier enables identification of application instance to facilitate recall, maintenance, transparency and traceability. |
Gora Datta | CAL2CAL | ||
| Level 0 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Food Allergy Intolerance | Common food substances and allergens that can cause harmful or undesirable physioloical responses when exposed to the substance or the substance is consumed. |
SNOMED CT with a value set created in VSAC (OID: 2.16.840.1.113762.1.4.1186.3) HL7 Cross Paradigm Specification: Allergy and Intolerance Substance Value Set(s) Definition: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=482 was used to create the value set |
Becky Gradl | Academy of Nutrition and Dietetics | |
| Level 0 | Outcomes | 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Referral note | Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Expanded list of clinical notes, detailed in Data Element Description | Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative) |
LOINC—although we would like to see the set of codes constrained as suggested above. In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability. |
KarenP-SSA | Social Security Administration (SSA) | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Clinical Notes for Newborn | Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge. |
LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Vital sign results: date and timestamps | LOINC codes for vitals—date and timestamps collected in standard format |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 0 | Outcomes | Occurrence | Time period of event – date/time, period, timing when the event occurred |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Detected | Date/Time the event was detected |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Recorded Date | When the event was recorded |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Resulting Effect | Effect on the subject due to the event |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Location | Location where adverse event occurred |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Outcomes | Recorder | Who recorded the adverse event |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Encounter status | 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 | ||
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Location Associated Time Period | Encounter type/occurrence: SNOMED CT (example, value set OID: 2.16.840.1.113883.3.666.5.307) HCPCS (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1087) CPT (example, value set OID: 2.16.840.1.113883.3.464.1003.101.12.1001) HL7 value set, encounter type: https://www.hl7.org/fhir/us/core/ValueSet-us-core-encounter-type.html Encounter Diagnosis/ Primary Diagnosis/Discharge Diagnosis: SNOMED CT ICD-10-CM Discharge Disposition: DischargeDisposition Code System http://terminology.hl7.org/CodeSystem/discharge-disposition Encounter Location: SNOMED HSLOC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| 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 | Outcomes | Study | Research study that the subject is enrolled in |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Pregnancy Information | Mother’s Prepregnancy Weight | The weight of the mother before becoming pregnant. |
LOINC codes exist for each of the proposed data elements: Last menstrual period start date: 8665-2 Delivery date Estimated: 11778-8 Body weight --pre current pregnancy: 56077-1 |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Plurality | The number of fetuses delivered live or dead at any time in the pregnancy regardless of gestational age, or if the fetuses were delivered at different dates in the pregnancy. (“Reabsorbed” fetuses, those which are not “delivered” (expulsed or extracted from the mother) should not be counted.) Include all live births and fetal losses resulting from this pregnancy. |
LOINC codes exist for each of the proposed data elements: 68493-6: Prenatal visits for this pregnancy # 69044-6: Date first prenatal visit 69461-2 Mother's body weight --at delivery 73772-6 The number of fetal deaths this delivery 73773-4 - Number of infants in this delivery delivered alive 57722-1 - Birth plurality of Pregnancy |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) |