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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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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 | 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.
|
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 | 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 | 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 | 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 | 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 | 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 | 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. |
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. |
Benefit Payment Status | Indicates the in network or out of network payment status of the claim. |
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. |
Procedure Code Type | Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Requested Procedure Identifier | The Requested Procedure is the unit of work resulting in one Diagnostic Imaging Report (https://www.healthit.gov/isa/taxonomy/term/2471/uscdi-v3#uscdi-proposal-mode-uscdi-data-element-page-display) with associated codified and billable acts. One or more Requested Procedures may have to be performed to satisfy an Imaging Service Request. Add info for field below: The current USCDI v2 Data Element, Diagnostic Imaging Test does not convey the hierarchy established in Diagnostic Imaging. The Order/Imaging Service Request generates one or more Requested Procedures, which generates one or more Scheduled Procedure Steps. See Appendix A, Clarification of Accession Number and Requested Procedure ID of Volume 1 of the IHE Radiology Technical Framework and DICOM Section 7.3 Extension of the DICOM Model of the Real World. | 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 |
Brian Bialecki | American College of Radiology | |
| 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. |
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 | Work Information | Job End Date | The last day a person worked in a Job. | Nedra Garrett | CDC | |||
| 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. |
Revenue Center Code | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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. |
Visual Acuity | Mike Schmidt | HiQ Services, LLC | |||
| 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. |