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 | Cancer Care | Radiation Therapy Prescription Number of Sessions Per Day | Used to capture BID, TID and other approaches intentionally treating more than one radiation therapy session per day to enhance biological effect. |
Elizabeth Covington | University of Michigan | |||
| 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. |
Type of Service | High level classification of services into logical grouping. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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 | Outcomes | Outcome Status | Adverse Event Status – i.e. in-progress, completed, entered-in-error, unknown | HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| 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. |
Allowed Number of Units | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. |
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. |
Modifier Code -1 | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. |
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. |
Modifier Code -2 | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. |
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 | Pregnancy Information | Gestational Age Determination Date | The date on which the estimated gestational age of pregnancy was determined. |
Value Set: Estimated Date of Delivery Including Method (https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.81/expansion) |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| 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. |
Care Team Member Completing Health Status Assessment | Care Team Member Conducting Health Status Assessment |
For the Care Team Member Identifier: National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID). |
Tayler Williams | American Medical Informatics Association (AMIA) | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Follow-Up | 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 |
Kevin Jung | University of California, San Francisco Breast Cancer Center | |
| Level 0 | Outcomes | Identifier | Business identifier for the event – important as multiple adverse events may affect a patient within the same visit or location. |
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.
|
Complications | 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 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| 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. |
Modifier Code -3 | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. |
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. |
<prTag>identifier | 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. |
Barry R Hieb | Global Patient Identifiers, Inc. (GPII) | |
| Level 0 | Social Determinants of Health | Self-Identified Need for Contraception (SINC) | Self-Identified Need for Contraception screening tool for primary care settings. |
Self-Identified Need for Contraception (SINC) LOINC: 98076-3 |
Dr. Christine Dehlendorf | Person-Centered Reproductive Health Program, Family and Community Medicine, University of California, San Francisco | ||
| 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 | Travel Information | Transportation Details | Information about transportation details such as the type of transport along with any associated information (e.g., name of cruise ship, flight number, airport, seat number, cabin number). |
HL7 FHIR: US Public Health Transportation Details profile HL7 CDA: Transportation Details Organizer/Transportation Details Observation templates VSAC Value Set: Transport vehicle type |
Nedra Garrett | CDC | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
HL7-Identifier | Globally unique identifier assigned to a patient by an organization asserting compliance with the referenced HL7 FHIR Identify Matching IG |
A system exists for using the identifier within HL7 FHIR transactions, particularly those invoking $match, but the standard also intends for the identifier to be used in other health information exchange transaction types as well as in non-healthcare specific transactions for example in OpenID Connect identity claims. |
Julie Maas | EMR Direct |