USCDI Export for the Public

The diagnosis specifies a patient’s concern/problem after a series of diagnostic tests and screening procedures by the healthcare provider. Beyond the encounter diagnosis (existing USCDI data element), the Encounter Information should include the mode of diagnosis. The key to cancer treatment is the type of tumor and the encounter data must include how the diagnosis was assessed as well as the critical features on pathology (including modern molecular tumor profiling).

ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10
SNOMED CT: https://www.snomed.org/

Assessment of a patient’s exposure to smoke emitted from tobacco products used by others.

Exposure to Second Hand Tobacco Smoke: SNOMED 16090371000119103 History of Exposure to Second Hand Tobacco Smoke: SNOMED 699009004 No Known Exposure to Second Hand Tobacco Smoke: SNOMMED 711563001 Second hand smoke exposure CPHS (Children’s preventive health services) LOINC: 39243-1

Highest level of education obtained. This is important for research and health care policy using social determinants of health (SDOH). Value should be as identified by patient. The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this element as high priority for routine collection.

Reference for value set items selected was American Community Survey https://www.census.gov/data/tables/2020/demo/educational-attainment/cps… .

Standard values identified are
None

Elementary School

High School Or GED

College no degree

Associates degree vocational

Associates degree academic

Bachelor's degree

Master's degree

Professional degree

Doctorate degree

American Community Survey
https://www.census.gov/data/tables/2020/demo/educational-attainment/cps…

Harmonization status indicates equivalency of results across platforms and vendors, ie, a harmonized test for a particular analyte and specimen yield results equivalent to other harmonized tests for that analyte and specimen. Harmonization is required for full clinical interoperability of test results. Results from harmonized tests may be interpreted and trended together, and may use the same calculation and decision support rules. Machine learning models may be trained and applied to data sets from different test platforms and vendors if the tests are harmonized. Tests that are not harmonized do not yield comparable results and should be interpreted and processed separately, not in aggregate with other tests. Incorrect assumption of harmonization status is a serious patient safety risk, and lack of harmonization information impedes public health interpretation of test results.

These proposed elements are a work in progress and the CAP urges that the vocabulary standards listed be considered for a future version of USCDI:

Reference Range:
The CAP proposes that the content of this data element follow the OBX-7 field from the HL7 2.5.1 standard. The CAP supports the use of the HL7 2.5.1 standard because the standard was designed to help laboratories comply with CLIA requirements. For numerical values, the CAP also proposes the Unified Code for Units of Measure (UCUM) standard. The CAP supports the use of the UCUM standard because it is well-established and because a common standard for units of measure will reduce errors related to translation of units of measure from one system to another.

Name and Address of Laboratory Location:
In lieu of a non-standard and inefficient textual description of a name and address, the CAP is proposing the use of the CLIA identification number as the data element content. All laboratories performing clinical testing have a CLIA identification number and are required to be able to report it, so the use of this number is not burdensome. The name and location of a laboratory can be determined quickly from the CLIA number using available online resources (for example, https://www.cdc.gov/clia/LabSearch.html).

Condition & Disposition of Specimens:
The CAP proposes the use of SNOMED CT for data element content. SNOMED CT is a relatively complete, well-curated, and actively-managed medical ontology that has excellent coverage of concepts appropriate for description of laboratory specimens, specimen sources, and conditions, and supports a rich array of hierarchical and other concept relationships.

Test Result Harmonization Status:
This is the first proposal of a harmonization status data element, and examples do not exist in other health data standards. Recently the ISO defined standard methods for harmonizing laboratory tests (see ISO 17511:2020 and 21151:2020). The CAP proposes development of a standard representation of these methods as content for this data element.

LOINC/RSNA Radiology Playbook includes Diagnostic Imaging Procedure Codes and Descriptions. HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM Release 1 references LOINC® Document Type Codes, SNOMED CT® Quantity Measurement Type Codes, as well as DICOM Code Systems. FHIR ImagingStudy references SNOMED CT Body Structures

Procedure provenance defines if the procedure was self-reported by the patient during the visit or completed by the provider.

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.

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.

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.

As part of an average week, on how many days does the patient perform muscle-strengthening activities such as weight or resistance training?

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.

Follow-up after interventions will assess the efficacy of different treatment modalities as well as potential post-treatment complications that can help inform clinical decision making.

ICD-10 and SNOMED CT

ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10
SNOMED CT: https://www.snomed.org/

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/

Globally unique identifier

ASTM/ANSI E 1714 Standard Guide for Properties of a Universal Healthcare Identifier (UHID), originally approved in 1995. Most recently approved in 2007.

AMIA recommends a more thorough breakdown of the Medical Devices Data Class. For medical devices, there should be a distinguishment between permanent versus temporary data classes. Temporary devices for example PICC line, indwelling foley and suprapubic catheters, and wound vacs. Medical applications should also be included as they are considered medical digital devices, such as digital therapeutics, standard languages, payor exchanges, what is included and excluded in this category.

FDA Unique Device Identification (UDI) System

The tidal volume set on the ventilator 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

The set respiratory rate 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

The pressure support above PEEP 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

The set positive end expiratory pressure (PEEP) if the patient is receiving mechanical ventilation or a biphasic positive airway pressure.

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

Numeric or alphanumeric code that uniquely identifies a document.