USCDI Export for the Public

Highest level of education obtained. This is important for research and health care policy using social determinants of health (SDOH). Value should be as identified by patient. The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this element as high priority for routine collection.

Reference for value set items selected was American Community Survey https://www.census.gov/data/tables/2020/demo/educational-attainment/cps… .

Standard values identified are
None

Elementary School

High School Or GED

College no degree

Associates degree vocational

Associates degree academic

Bachelor's degree

Master's degree

Professional degree

Doctorate degree

American Community Survey
https://www.census.gov/data/tables/2020/demo/educational-attainment/cps…

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.

Harmonization status indicates equivalency of results across platforms and vendors, ie, a harmonized test for a particular analyte and specimen yield results equivalent to other harmonized tests for that analyte and specimen. Harmonization is required for full clinical interoperability of test results. Results from harmonized tests may be interpreted and trended together, and may use the same calculation and decision support rules. Machine learning models may be trained and applied to data sets from different test platforms and vendors if the tests are harmonized. Tests that are not harmonized do not yield comparable results and should be interpreted and processed separately, not in aggregate with other tests. Incorrect assumption of harmonization status is a serious patient safety risk, and lack of harmonization information impedes public health interpretation of test results.

These proposed elements are a work in progress and the CAP urges that the vocabulary standards listed be considered for a future version of USCDI:

Reference Range:
The CAP proposes that the content of this data element follow the OBX-7 field from the HL7 2.5.1 standard. The CAP supports the use of the HL7 2.5.1 standard because the standard was designed to help laboratories comply with CLIA requirements. For numerical values, the CAP also proposes the Unified Code for Units of Measure (UCUM) standard. The CAP supports the use of the UCUM standard because it is well-established and because a common standard for units of measure will reduce errors related to translation of units of measure from one system to another.

Name and Address of Laboratory Location:
In lieu of a non-standard and inefficient textual description of a name and address, the CAP is proposing the use of the CLIA identification number as the data element content. All laboratories performing clinical testing have a CLIA identification number and are required to be able to report it, so the use of this number is not burdensome. The name and location of a laboratory can be determined quickly from the CLIA number using available online resources (for example, https://www.cdc.gov/clia/LabSearch.html).

Condition & Disposition of Specimens:
The CAP proposes the use of SNOMED CT for data element content. SNOMED CT is a relatively complete, well-curated, and actively-managed medical ontology that has excellent coverage of concepts appropriate for description of laboratory specimens, specimen sources, and conditions, and supports a rich array of hierarchical and other concept relationships.

Test Result Harmonization Status:
This is the first proposal of a harmonization status data element, and examples do not exist in other health data standards. Recently the ISO defined standard methods for harmonizing laboratory tests (see ISO 17511:2020 and 21151:2020). The CAP proposes development of a standard representation of these methods as content for this data element.

As the use of medical cannabis, OTC cannabidiol (CBD), and adult use cannabis (medical marijuana), and recreational cannabis is more frequent - there is the potential for drug-drug interactions; and awareness for peri-operative elective or urgent surgical procedures and/or hospitalizations. It is not just the added sedation - and perhaps safer than opioids - but the emphasis here is that cannabinoids have the real potential to affect the metabolism of OTHER medications especially those that have a narrow therapeutic index or other medications that have high-protein binding. A standardized format will provide the foundation for drug-drug interaction screening - vs. a multitude of inconsistent entries. Although medical cannabis is technically DEA class-1; there is high probability that medical cannabis may be transitioned to DEA class-3 in the very near future (see recent CSR memo added to the 'Use Case' tab). Additionally, this idea is also for cannabidiol (CBD) which is over the counter (OTC) - so not just limited to prescription Epidiolex. Additionally, medical cannabis preparations often have unique dosage forms (e.g., badder, butter).

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

Standard Date/Time formats

HL7 FHIR US Core ServiceRequest Category Codes HL7 Service Request Category

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.

<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.

As part of an average week, on how many days does the patient perform muscle-strengthening activities such as weight or resistance training?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

For an average week in the last 30 days, how many minutes per week did the patient engage in moderate to vigorous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

Procedure provenance defines if the procedure was self-reported by the patient during the visit or completed by the provider.

For an average week in the last 30 days, how many days per week did the patient engage in moderate to vigorous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

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

On those days that the patient engages in moderate to vigorous exercise, how many minutes, on average, do they exercise?

The following LOINC codes correspond to components of the proposed measures: 89555-7 – Physical Activity – Days/Week 68516-4 – Physical Activity – Minutes/Day 82291-6 – Physical Activity – Muscle-Strengthening For the overall minutes/week measure, there is a standard LOINC code 89574-8 – Exercise Vital Sign that groups the Days/Week and Minutes/Day component, however it does not actually support capturing the calculated Minutes/Week component, even though the submitter of the code (Kaiser Permanente) makes regular use of the calculated value. HL7 will work with Kaiser and Regenstrief to either allow the existing ‘panel’ code to capture the calculated days/week measure or add an additional component that supports the calculation, making it easier to query for patients outside guideline without requiring client-side calculation.

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.

Assessment of or screening for the presence of a mental or behavioral health condition.

Various specific mental health status measures exist in LOINC, including the PHQ-9 for depression, the GAD-7 for anxiety, and the C-SSRS for suicide risk.

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.

To be used with trauma patients to have activation type (full, partial or activation/alert, etc.) and date/time of trauma activation type.

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
SNOMED CT: https://www.snomed.org/