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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
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:
• International Classification of Diseases, 10th version, Clinical Modification (ICD-10-CM) guidelines for coding and reporting and includes specific guidelines on inclusion of secondary codes needed to properly code a neoplasm.
• SNOMED CT, which includes dedicated codes for describing metastatic malignant neoplasms.
• International Classification of Diseases for Oncology version 3 (ICD-O-3), which includes codes that assert a neoplasm is metastatic.

 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.
mCODE further specifies a value set of SNOMED CT codes for cancer staging systems (http://hl7.org/fhir/us/mcode/ValueSet-mcode-cancer-staging-system-vs.ht…).

 May Terry MITRE Corporation
Level 0 Problems

Condition, diagnosis, or reason for seeking medical attention.

 Date of First Noted/Documented

Date of first noted/documented by a qualified professional of the presence of a problem or condition affecting a patient.

Standard Date/Time formats

 Tayler Williams American Medical Informatics Association (AMIA)
Level 0 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 Country of Usual Residence

The patient’s usual country of residence

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: Country of Residence profile HL7 CDA: Country of Residence template

 Laura Conn
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.

 HHS Disability Status - Activities of Daily Living

According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have difficulty dressing or bathing?”

HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC)

 Nedra Garrett CDC
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
LOINC:86645-9
Example answer list:
Answer
Yes, I want to become pregnant; LA26438-4
I'm OK either way; LA26439-2
No, I don't want to become pregnant; LA26440-0
Unsure; LA14072-5

SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22

 Emily Decker Upstream USA
Level 0 Work Information Job Employer Name

The company, organization, or individual that provides compensation for a job or that assigns work to a volunteer, as reported by the person. For a military position, this is the self-reported duty station (home base).

LOINC® 80427-8 Employer name

 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.

 Quantity Qualifier Code

The unit of measurement for the drug. (gram, ml, etc.).

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Nutrition and Diet Oral Diet Nutrient Modifiers Nutrients that are increased or decreased in conjunction with the oral diet type as part of a therapeutic diet. For example, “decreased sodium” or “increased protein”.

HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317) HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html) In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples: Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

 Becky Gradl Academy of Nutrition and Dietetics
Level 0 Patient Demographics/Information

Data used to categorize individuals for identification, records matching, and other purposes.

 <prTag>status

<prTag> status is a character string that gives the status of its associated <prTag>. Possible values include:
“active”, “locked”, “terminated”, or “invalid”

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 Outcomes Detected

Date/Time the event was detected

HL7.org FHIR R4 v4.0

 Sandi Mitchell J P Systems, Inc.
Level 0 Outcomes Recorded Date

When the event was recorded

HL7.org FHIR R4 v4.0

 Sandi Mitchell J P Systems, Inc.
Level 0 Provenance

The metadata, or extra information about data, regarding who created the data and when it was created.

 Element Level GUID

The Element Level Globally Unique Identifier (GUID) ensures that each data element instance:
1) Has a single non-duplicative identifier;
2) Assigned at the point of origination by the source EHR/PHR/HIT system;
3) Inseparably bound to the data element instance;
4) Maintained in perpetuity during the lifespan of that data element instance;
5) From source to use (point of origination to each ultimate point of use), including all intermediate stages and lifecycle events (retention, update/amendment, verification/attestation, exchange...).
6) Can be bound together within a correlated set - elements of content bound to elements of related context.

 Gary Dickinson EHR Standards Consulting
Level 0 Outcomes Resulting Effect

Effect on the subject due to the event

HL7.org FHIR R4 v4.0

 Sandi Mitchell J P Systems, Inc.
Level 0 Referral Referral Category The classification of the referral, or the service being requested. For example a procedure, an intervention such as counseling or education, or a service.

HL7 FHIR US Core ServiceRequest Category Codes HL7 Service Request Category

 Grace Glennon, on behalf of NCQA NCQA
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.

 Quantity Dispensed

Quantity dispensed for the drug.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
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 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 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 Genomics Molecular Consequence

Molecular consequence is a calculation of the effect of the sequence change if the allele is in a gene (source: NCBI, https://www.ncbi.nlm.nih.gov/clinvar/docs/details/).

The Sequence Ontology is a collaborative ontology project for the definition of sequence features used in biological sequence annotation.

 May Terry MITRE Corporation