USCDI Export for the Public

The following value should be used to document patient consent during a disaster or pandemic in Texas: TXD – Disaster consent In Texas, there is legislation that requires health care providers to report antiviral, immunization or other medications (AIM) administered to patients in response to a disaster such as COVID-19. When the AIM information is reported the TX IIS (ImmTrac) flags the information as disaster-related. If the patient signs the disaster-related consent form, their personal and disaster related AIMs are stored for the patient’s lifetime. If the patient does not sign the disaster related consent form or the regular, applicable consent form but receives a disaster related AIM, then their personal information and disaster related AIMs are stored in Texas’ IIS for up to 5 years after the end of the disaster. It is crucial for Electronic Health Records to capture, store, and exchange information regarding whether the patient received an AIM that was administered in response a disaster/pandemic so that this information can be shared with others to ensure appropriate medications are delivered and patient health can be maximized..

Indicates the reason the immunization event was not performed.

Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html

Medical orders guide what medical interventions providers will perform for a patient. A portable medical order is a type of medical order. Portable medical orders are not authored by patients. They are authored by practitioners in the context of an electronic medical record system. The medical orders are provided to the patient in the form of a document so the orders can travel with the patient and be exchanged with other care providers who do not have access to the EMR where the orders originated. Medical orders regarding life-sustaining treatments are established by a practitioner regarding treatments that restore, sustain or prolong a patient’s life. These types of medical orders are intended to be consistent with the patient’s instructions and wishes. Orders to perform or not perform specific types of life-sustaining treatments are documented by physicians as medical orders within the EMR system used by the organization providing medical interventions or the practitioner’s EMR. When medical orders regarding life-sustaining treatment are produced in a portable format, they are portable medical orders for life-sustaining treatment. Currently, there is no national standard for the expected content in a portable medical order for life-sustaining treatments, as the content can vary by State and EMR system. All doctors, emergency medical professionals, and other healthcare professionals, must follow these medical orders as the patient moves from one location to another (hospital, care facility, home, etc.), unless a treating physician examines the patient, reviews the medical order for life-sustaining treatment, and through conversation with the patient detects the need for a replacement order or as a result of their own clinical judgement creates a replacement order. In an emergency situation, characterized by a life-threatening health crisis, if the patient is unable to speak for themselves, life-sustaining treatments and procedures that are legally required of medical and emergency personnel can be overridden by a valid portable medical order. Depending on the state, a portable medical order may go by any of the following names: • MOLST (Medical Orders for Life-Sustaining Treatment) • POLST (Physician Orders for Life-Sustaining Treatment) • MOST (Medical Orders for Scope of Treatment) • POST (Physician Orders for Scope of Treatment) • TPOPP (Transportable Physician Orders for Patient Preferences) • Out-of-hospital Do Not Resuscitate (DNR) Orders The above forms have historically been paper-based and siloed in EMRs that might contain a scanned image, or a clinical note that details the decisions documented in the portable medical order. Emergency and treating care teams do not have mechanisms for establishing that the copy they are provided is the most current version and that another, more recent portable medical order doesn’t exist that would contradict the order they are reviewing. These uploaded copies of the portable medical order for life-sustaining treatment are considered to be just as valid as the original paper medical order that was provided by a physician to the patient for whom it was written. The currently supported digital interchange format for portable medical orders is a pdf document, as there are not standard interoperable data elements. The pdf document can be represented as a C-CDA Unstructured Document or a FHIR DocumentReference to enable key administrative information to be processed.

Portable Medical Orders for Life Sustaining Treatment The currently supported digital interchange format for portable POLST orders is a pdf document. The pdf document can be represented as a C-CDA Unstructured Document or a FHIR DocumentReference to enable key administrative information to be processed. There is no standard guidance about the expected content in a portable medical order for life sustaining treatments. The content varies by state and by EMR system. Portable Medical Orders for Life Sustaining treatment are a type of Medical Order. Data Element Code Definition Portable medical order form 93037-0 LOINC urn:oid:2.16.840.1.113883.6.1 Physician Order for Scope of Treatment which encompasses Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). MOLST Observation In the context of a Patient Summary or Encounter Summary authored by a clinician or assembled by clinician’s EMR system, observations verifying a patient’s advance directive information and medical orders for life sustaining treatments using established standards for recording this type of information documented by providers. If a person has a medical order or physician order for life sustaining treatment (MOLST or POLST). This observation does not indicate what orders are included in the MOLST or POLST. It indicates if a MOLST or POLST exists. If a MOLST or POLST exists, the template includes a reference structure that can be used to point to the MOLST or POLST document. The vocabulary and structure needed to express this observation is provided in the HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 August 2020 Volume 2 – Templates. This observation can be used to document a patient authored statement about portable medical orders for life sustaining treatments or physician authored statements about there being portable medical orders for life sustaining treatments. Note that a physician’s own medical orders placed for life sustaining treatments are documented as medical orders placed within the physician’s own EMR.

The date the vaccination event occurred.

LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/

Dates planned for travel to a location.

Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html)

When the event occurred

adverse events are mapped to MedDRA terminology

Information on the possible cause of the event

adverse events are mapped to MedDRA terminology

Type of the event itself in relation to the subject

adverse events are mapped to MedDRA terminology

The suspected agent causing the adverse event

adverse events are mapped to MedDRA terminology

The NIAAA Single-Item Screener is a single question that may be used to screen men and women (separately) for unhealthy alcohol use. It has been validated in primary care settings; the specific language for men and women appears below. Men: How many times in the past year have you had five or more drinks in a day? Women: How many times in the past year have you had four or more drinks in a day?

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

The AUDIT-C is a three-item measure to screen for alcohol-related problems. Questions and answers include: 1. How often do you have a drink containing alcohol? (Response choices: Never/Monthly or less/2-4 times per month/2-3 times per week/4 or more times per week) 2. How many standard drinks containing alcohol do you have on a typical day? (Response choices: 1-2/3-4/5-6/7-9/10 or more) 3. How often do you have six or more drinks on one occasion? (Response choices: Daily or almost daily/Weekly/Monthly/Less than monthly/Never)

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

Represents a location in a person’s travel plans (either an address or a coded location).

§ SNOMED: 420008001 |Travel (event)| § Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.do 11.3201) § ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) § NCI_Thesaurus 22.08e: code C173619 § LOINC v2.72 code: PhenX measure - international travel history:-:Pt:^Patient:-:PhenX (Code 62887-5)

This data element describes whether an individual sought help for alcohol-related problems during pregnancy

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

This data element captures the Alcohol Use Disorder (AUD) diagnosis, which reflects the current nosology for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

This data element includes whether an individual has received a diagnosis of alcohol abuse or dependence, as per the DSM-IV nosology

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

This data element provides a measure of an individual’s average daily alcohol intake, i.e., how many drinks per day someone has

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

This data element denotes whether an individual currently consumes alcohol or not

Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0

Military service in the armed forces of the United States or other nations, including the length and branch of service, the military occupation, the location and type of duty (e.g., in the United States or abroad with combat, combat support, or noncombat duties), and any ongoing illness, injury, limitation, or disability that began during military service. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 297 (2014).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

Data element capturing the refugee status of a patient

Veteran Status: Z56.82 Military deployment status Farmworker Status: ICD: Z57.2 Occupational exposure to dust Z57.3 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.6 Occupational exposure to extreme temperature Z57.8 Occupational exposure to other risk factors Agricultural/animal husbandry worker (occupation) - SNOMED: 106390009 Refugee Status: Refugee family (social concept) - SNOMED: 413323004 Refugee (person) - SNOMED: 446654005 Are you a refugee? - LOINC: 93027-1 Refugee - LOINC: LA29153-6

standard date formats