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 | Newborn's Delivery Information | CCHD Newborn Screening Interpretation | The result of the screening of the preductal and postductal oxygen saturation measurements. |
LOINC 73700-7 - CCHD newborn screening interpretation |
Craig Newman | Altarum | ||
| 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. |
Health Literacy Status | Degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. | LOINC 95866-0, BRIEF health literacy screening tool [BRIEF]; LOINC LL3268-1 (for answers) |
Nedra Y Garrett | CDC | |
| 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 | 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. |
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 | Outcomes | Oncology Adverse events | complications (serious- hospitalization, death) |
Laura Esserman | University of California - San Francisco | |||
| 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. |
Claim Adjusted from Identifier | If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number |
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. |
Payer Claim Unique Identifier | Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a 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. |
Member Discharge Date | Date the beneficiary was discharged from the facility, or died. Matches the Statement Thru Date. When there is a discharge date, the Patient Discharge Status Code indicates the final disposition of the patient after discharge. |
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. |
Member Admission Date | The date corresponding with admission of the beneficiary to a facility and the onset of services. May precede the Statement From Date if this claim is for a beneficiary who has been continuously under care. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Immunizations | Record of vaccine administration. |
Patient Assertion of Vaccine Credentials | Whether or not the patient asserts they have verifiable vaccine credentials. |
HL7 FHIR: Vaccine Credential Patient Assertion Observation profile HL7 CDA: Vaccine Credential Patient Assertion Observation LOINC: 11370-4 "Immunization status - Reported" |
Nedra Garrett | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication List Type | Codification of the type of medication list (e.g. Active medication list, Reconciled medication list, Discharged medication list, Discontinued (Inactive) medication list, Patient generated medication list (Different nuance, needs to be reviewed by a clinician before it can be entered as an active medication list), Medications that are private and need patient consent to share, Medication administration list, Medication administration list for public health and CDC reporting (e.g., for COVID, Antibiotics for Antibiotic Stewardship), Discharged medication list (Feeds the discharge summary that contains the Discharged medication list and when transferring within a hospital from one level of care to another (intersystem), a transfer medication list is used for MR). |
LOINC |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 0 | Substance Use | Alcohol binge episodes per month | This data element comprises how many alcohol binge episodes an individual has per month |
Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0 |
Laura Kwako | National Institute on Alcohol Abuse and Alcoholism | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Country of Nationality | The patient's country of nationality. |
HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 |
Sarah Gaunt | ||
| 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. |
Social History Observation | In CCDA 2.1, the Social History Section and Observations recommend use of SNOMED CT codes that are members of the Social History Type Set Definition 2.16.840.1.113883.3.88.12.80.60 Value Set, but there are many other potential codes and code sets to represent values associated with Social Risk Factor assessment, observations, diagnoses and interventions. |
Al Taylor | ONC | ||
| Level 0 | Social Determinants of Health | Congregate Living | Shared housing includes a broad range of settings, such as apartments, condominiums, student or faculty housing, national and state park staff housing, transitional housing, and domestic violence and abuse shelters | HL7 CDA: C-CDA Characteristics of Home Environment template HL7 FHIR: US Public Health Characteristics of Home Environment LOINC: 75274-1 "Characteristics of residence" Value set: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.49/expansion (Residence and Accommodation Type) |
Nedra Garrett | CDC | ||
| Level 0 | Patient Summary and Plan | Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment. |
Clinical Decision Support Data | Data and reporting used for risk stratification, optimization of patient outcomes, detection of decompensation, clinical and patient education. |
SNOMED CT |
Grace Cordovano | Enlightening Results | |
| Level 0 | Work Information | Occupational Exposure/Hazard | A hazard that is specific to a person's work or work environment for a single job and with which the person might come in contact. A hazard is a source of potential harm to an individual's physical or mental health (e.g., biological, chemical, physical, psychological, radiological). |
LOINC History of Occupational hazard | 87729-0 |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Pregnancy Information | Planned Pregnancy | Assessing patients for planned pregnancy information reduces the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, provide education and interventions. |
SNOMED CT |
Andrea Fourquet | IHE USA |