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 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 - Vision

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: “Are you blind or do you have serious difficulty seeing, even when wearing glasses?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0

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

Nedra Garrett CDC
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 Work Information Job Employer Address

The self-reported Employer Address; this is not necessarily the work location.

LOINC (r) 80429-4 Employer address

Nedra Garrett CDC
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 Cancer Care Radiation Therapy Dose Objective

TG-263 (https://www.aapm.org/pubs/reports/RPT_263.pdf) name of DVH metric for the objective

Elizabeth Covington University of Michigan
Level 0 Work Information Job Start Date The date a person started working in a Job. Nedra Garrett CDC
Level 0 Work Information Usual Occupation Duration The self-reported total of all periods of time (in years) a person has spent in their Usual Occupation as of the date recorded, not including intermittent period(s) when the person was not working in that occupation. It is recorded as an integer to one decimal place. Nedra Garrett CDC
Level 0 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Reported Medication (unique)

“Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record.” (from FHIR R4 MedicationRequest.reported[x]). This would clearly identify a medication that only exists in the data system not as part of any direct data for an original prescription (within the same EHR or across an EHR network, etc) but, instead, via descriptive communication or narrative (verbal, written, etc) by a relevant person (the patient, family, a caregiver, another physician, etc.) This may either be represented as a simple Boolean choice or, additionally, include information of the person and/or nature of the reporting. Additionally, some standards and system implementations provide more than one location for this type of information – and different options are used by different implementations resulting in highly non-standardized usage of this critical information. Proposal is that this information is captured ONLY in one way, universally across systems.

In FHIR R4, MedicationRequest.reported[x] (https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.reported_x_) supplied either a boolean or Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) In FHIR R4 MedicationStatement - FHIR v4.0.1 (https://www.hl7.org/fhir/medicationstatement.html) which is still sometimes used to represent reported medications, a number of key terminologies are utilized

Scott Gordon Food and Drug Administration
Level 0 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Medication Prescription Do-Not-Perform

Do-not-perform is an additional Boolean element in HL7 FHIR R4 Medication Request representing the provider’s intent that the prescription NOT be carried forward. If it is assumed that Status will be updated based on this command (ie, status will be changed to “cancelled” then this may be redundant. Alternative is an additional Status of “cancelled-by-provider”

In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.status

Scott Gordon Food and Drug Administration
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 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 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Therapeutic Medication Response

Represents a therapeutic response (as opposed to an undesired reaction) to the administration of a medication.

HL7 FHIR: Therapeutic Medication Response extension HL7 CDA: Therapeutic Medication Response observation LOINC: 67540-5 "Response to medication" VSAC Value Set: Therapeutic Response to Medication

Laura Conn
Level 0 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Medication Prescription Patient The person who is the intended recipient of the medication. While seemingly self-evident as a part of an prescription record, the requirement of the patient being linked to the drug administered is critical

In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.subject

Scott Gordon Food and Drug Administration
Level 0 Medications

Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.

Medication Knowledge

The MedicationKnowledge resource is draft and is included for comment purposes. This resource represents information about a medication, for example, details about the medication including interactions, contraindications, cost, regulatory status, administration guidelines, etc. https://www.hl7.org/fhir/medicationknowledge.html

RxNorm and SNOMED CT

Shelly Spiro Pharmacy HIT Collaborative
Level 0 Work Information Usual Occupation Start Date The self-reported year that a person started working in their Usual Occupation. Nedra Garrett CDC
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 Work Information Job Work Classification

A coded term that characterizes the arrangement between the employer and the person in a job, such as 'paid work, self-employed' or 'voluntary work in disaster/emergency response', as reported by the person.

PHVS_WorkClassification_ODH

Nedra Garrett CDC