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 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Present on Admission | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Diagnosis Code Type | ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Diagnosis Type | ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Biologically Derived Product | Material substance originating from a biological entity intended to be transplanted or infused into another (possibly the same) biological entity. |
Unique Identifier for a Medical Product of Human Origin | The globally unique identifier for each blood or biologic product identified using the ISBT 128 international standard. |
ISBT 128 |
Karen Moniz | ICCBBA | |
| Level 0 | Explanation of Benefit | Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data. |
Diagnosis Code Type | Indicates if the diagnosis is admitting, principal, other, an external cause of injury or secondary |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Organ Donor | Represents the wishes of an individual to donate their organs, tissues, and/or blood as a deceased or living donor. |
Grace Cordovano | Enlightening Results | ||
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Data Steward | Patients may be their own data stewards, or have other data stewards able to authorize permissions on their data. This term, "Data Steward" is intended to describe an individual or organization authorized and accountable for permission decisions about the health data of the individual. While this may be a RelatedPerson or a member of a CareTeam (existing elements and classes in USCDI FHIR), it may also not be part of those groups. Data stewards may be needed for individual patients who are incapacitated or for minors who lack legal capacity to consent (although be able to assent). Data stewards may also have a critical role in stewardship of health data for deceased individuals, e.g. clinical genetic counseling, research studies. Individuals may also assign stewardship to multiple individuals and organizations. Data stewardship may also authorize designated organizations and/or individuals to determine data use permissions by specific segment (e.g. medication data vs. family history data). |
FHIR has standards for Person and Organization resources: https://www.hl7.org/fhir/person.html https://www.hl7.org/fhir/organization.html However, role-specific terminology and standards may be needed to describe the specific role(s) of a Data Steward if considered as a separate element, or as a member of the CareTeam. |
Henry Wei | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administrations Report (Flowsheet) | Structured data captured in a Medication Administration Report (usually for inpatients) showing each drug administered, who administered it, what time it was administered, etc. |
LOINC has codes for flowsheet elements/structured clinical data including for prenatal, cancer staging, and medication administration (clinical LOINC), FHIR R4 Observation resource, MedicationAdministration, among others, can be used to communicate the information. |
TICIA Louise GERBER | Health Level Seven International | |
| Level 0 | Research Data | Study Name | Study subject is part of |
CDISC standards, HL7 FHIR researchstudy, researchsubject (formerly known as Data Access Framework (DAF)) |
Mitra Rocca | Food and Drug Administration | ||
| Level 0 | Research Data | Clinical Trial Participation State | Indicator of the progression of a study subject through a study. |
CDISC standards, HL7 FHIR research-study-state, researchsubject (formerly known as Data Access Framework (DAF)) |
Mitra Rocca | Food and Drug Administration | ||
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory results: date and timestamps | Date and timestamps associated with the completion of laboratory results, that are meta data associated with laboratory results |
LOINC codes for labs—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 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Laboratory Test Performed Date | The clinically relevant date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained. |
Laboratory Test/Panel Code: LOINC Codes: http://loinc.org Laboratory Test Performed Date: FHIR dateTime, Period, Timing, Instant: http://hl7.org/fhir/observation-definitions.html#Observation.effective_x_ Laboratory Result Status: FHIR Observation Status: http://hl7.org/fhir/valueset-observation-status.html Laboratory Result Value: FHIR Quantity|CodeableConcept|string|boolean|integer|Range|Ratio|SampledData|time|dateTime|Period: http://hl7.org/fhir/observation-definitions.html#Observation.value_x_ |
Maria Michaels | CDC | |
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Accession number | The unique identifier for a single instance of a specimen received by a laboratory and its analysis. |
Riki Merrick | Association of Public Health Laboratories | ||
| 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. |
Audiogram | Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide |
Troy Kaji | Contra Costa Health Services | ||
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Proxy Decision Maker | Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable. |
Holly Miller, MD | MedAllies | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Tribal Enrollment | A tribe of which the patient is an enrolled member. |
HL7 FHIR: US Public Health Tribal Affiliation extension |
Laura Conn | ||
| Level 0 | Pregnancy Information | Pregnancy Intention Screening | Screening patient for their desire to become pregnant in the next 12 months in order to determine which reproductive health services may be relevant to offer the patient in that encounter. |
Pregnancy Intention Screening Question: Pregnancy intention in the next year - Reported SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22 |
Emily Decker | Upstream USA | ||
| 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. |
Insomnia Screening | Insomnia is a very common complaint in the general population and can contribute to a state of inadequate or mistimed sleep, which can affect general health, mental wellbeing and daytime functioning. Several screening tools exist to identify and severity of insomnia, including the Insomnia Severity Index. Insomnia is a common, treatable condition that often goes undiagnosed and can negatively affect general physical and mental health. Insomnia is very common, the American Academy of Sleep Medicine reports that approximately 30% - 40% of US adults report symptoms of insomnia at some point in a given year. Insomnia is a common, treatable condition that often goes undiagnosed and can nagatively affect general physical and mental health. Charles M. Morin, PhD, Geneviève Belleville, PhD, Lynda Bélanger, PhD, Hans Ivers, PhD, The Insomnia Severity Index: Psychometric Indicators to Detect Insomnia Cases and Evaluate Treatment Response, Sleep, Volume 34, Issue 5, 1 May 2011, Pages 601–608, https://doi.org/10.1093/sleep/34.5.601 |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| 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. |
Sleep Log /Diary | A patient with a sleep problem will often be asked to keep a Sleep Log or Diary , record of sleep behaviors usually including sleep time. wake time, sleep duration, frequency and duration of sleep interruptions, medications, perceived sleep quality, caffeine intake, etc. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| 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. |
Obstructive Sleep Apnea Screening | The recognition of Obstructive Sleep Apnea (OSA) is important in reducing the disease burden of cardiovascular disease. OSA is strongly correlated with cardiovascular disorders and management of this condition may facilitate better control of cardiovascular disorders leading to improved patient outcomes. Several OSA screening tools exist, including the STOP Questionaire and the Epworth Sleepiness Scale. Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008:108;812-21. Johns MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991; 14(6):540-5. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH |