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 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator set tidal volume | The tidal volume set on the ventilator if the patient is receiving mechanical ventilation. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator Mode | The mode of mechanical ventilation if the patient is receiving mechanical ventilation. Could refer to LOINV 20124-4 for options. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator measured plateau pressure | The measured plateau pressure on the ventilator if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Measured ventilator peak inspiratory pressure | Measured peak inspiratory pressure if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Name | The name of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Use | The use of the medical device. |
Sandi Mitchell | J P Systems, Inc. | ||
| 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. |
Nutrition Status | A systematic nutrition assessment of an individual's nutrition intake, physical exam, anthropometric measurements, biochemical, and health condition data compared to accepted standards, recommendations, and/or goals to arrive at a determination of the client’s nutrition well-being or malnutrition. |
LOINC 75304-6 Nutrition status observation panel |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| 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. |
Pain Assessment | An assessment of a person’s pain, which could include assessment of acute and chronic pain using standardized assessment tools. Assessments of pain include but not limited to pain severity, interference of pain on activity, and pain impact on mood or sleep using unidimensional or multidimensional assessment tools. | LOINC and SNOMED CT |
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| 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. |
Depression Screening | Assessment of clinical depression using standardized tools. |
LOINC |
Grace Glennon, on behalf of NCQA | NCQA | |
| 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 | Genomics | Variant Clinical Significance | Clinical significance is an assessment of the magnitude of a genetic variant's clinical effects as per estimates supplied by researchers and/or guidelines (source: HL7 Clinical Genomics Working Group). |
LOINC is the reference terminology proposed by the HL7 Genomics Reporting FHIR IG (http://hl7.org/fhir/uv/genomics-reporting/index.html) for codifying the ACMG clinical significance categories (https://loinc.org/LL4034-6/) |
May Terry | MITRE Corporation | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Start/End Date | The start and end date of a medication order. |
Sandi Mitchell | J P Systems, Inc. | ||
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Total Output | The total volume that the patient put out during a calendar day, from all sources, including urine, stool, and drains like chest tubes, surgical drains, intrathecal catheters, external ventricular drains, peritoneal catheters. | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Urine Output | The total urine output during a calendar day, from all sources including voids, bladder catherization, urostomy, nephrostomy tubes. | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Total Intake | The total volume that the patient received during a calendar day, through all sources of access (e.g. intravenous, enteral, oral, peritoneal, pleural, intrathecal, intravesicular, rectal) | LOINC 9097-7 Fluid balance 24hrs SNOMED CT 251856003 Fluid balance |
Ali Abbas MD | UCSF | |
| Level 0 | Cancer Care | Secondary Cancer Condition | Also known as secondary malignant neoplasm, secondary cancer condition is used to describe either a new primary cancer or cancer that has spread from the place in which it started to other parts of the body (Source: NCI). |
Three terminologies are commonly referenced for the exchange of secondary/metastatic cancer conditions: |
May Terry | MITRE Corporation | ||
| Level 0 | Cancer Care | Staging System | A cancer staging system is used to describe the extent of cancer in the body. There are many staging systems. Some, such as the TNM staging system, are used for many types of somatic cancer. Others are specific to a particular type of cancer (Source: NCI). Examples of non-TNM staging systems include the Cotswolds Modifications of the Ann Arbor Staging Classification, Revised International Staging System (R-ISS), and Rai and Binet staging systems for chronic lymphocytic leukemia. |
SNOMED CT specifies codes for describing different cancer staging systems. |
May Terry | MITRE Corporation | ||
| Level 0 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Individual Administering Vital Signs | Identify the role of the individual taking the vital signs, differentiating between inputs that are from a care team member, patient or family/caregiver, as separate from an automated device or home monitoring system. |
For care team members: Examples include but are not limited to National Provider Identifier (NPI) and National Council of State Boards of Nursing Identifier (NCSBN ID). For FDA approved devices: FDA Unique Device Identification (UDI) System |
Tayler Williams | American Medical Informatics Association (AMIA) | |
| Level 0 | Encounter Information | Information related to interactions between healthcare providers and a patient. |
Trauma Activation or Trauma Alert Type with Activation Date and Activation Time | To be used with trauma patients to have activation type (full, partial or activation/alert, etc.) and date/time of trauma activation type. |
Valerie Brockman | UCHealth | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
<prTag>timestamp | The time stamp indicates the time the <prTag> is created. |
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) |