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 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Custodian Organization Telecom | A telecom of the custodian organization. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Initial evaluation note | Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component. |
LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/ |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 0 | Nutrition and Diet | Enteral Nutrition Volume | The volume of formula to provide at each feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements. | 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 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Custodian Organization Id | An identifier of the custodian organization. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| 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 | Cancer Care | Radiation Therapy Outcome/Disease Status | Status of the disease treated with radiation therapy at the time of the record. Under Treatment No evidence of disease (NED) Stable Disease Partial Response Progressive Disease Indeterminate (possible pseudo-progression) Complete Response Biochemical Recurrence Primary Recurrence Local Recurrence Nodal Recurrence Distant Recurrence In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Disease Status can be selected e.g. Biochemical Recurrence, Nodal Recurrence |
Charles Mayo | University of Michigan | |||
| Level 0 | Cancer Care | Provider Reported Toxicity Measure | For each Cancer Patient - Provider Reported Toxicity record the Toxicity Measure specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) is used then the Toxicity Measure would correspond to CTCAE Term (e.g. Dry Mouth, or Dry Mouth) The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy |
Common Terminology Criteria for Adverse Events |
Charles Mayo | University of Michigan | ||
| Level 0 | Nutrition and Diet | Oral Nutritional Supplement | A food item consumed to manage calories, protein or other nutrient(s) to enhance nutritional quality; the supplement could be a meal replacement, a part of a meal or consumed as a snack. Examples: Commercial ready-to-use beverages or powdered products to be reconstituted with milk/milk substitute or water, puddings, soups or bars. | 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 | Cancer Care | Provider Reported Toxicity Value | For each Cancer Patient - Provider Reported Toxicity record the Toxicity Value corresponding to the Toxicity Measure specified indicates the severity of the toxicity using the standardized table. specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) the values in the standardized set are 0,1,2,3,4,5 The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy |
Common Terminology Criteria for Adverse Events |
Charles Mayo | University of Michigan | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Summarization of encounter note narrative | A clinical note which narratively summarizes the patient encounter. LOINC code = 67781-5. |
LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/ |
Nedra Garrett | Centers for Disease Control and Prevention | |
| 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. |
Line Payment Amount | The amount sent to the payee from the health plan. This amount is to exclude any member cost sharing. It should include the total of member and provider payments. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Proxy Decision Maker | Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable. |
Holly Miller, MD | MedAllies | ||
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Unique Identifier | Numeric or alphanumeric code that uniquely identifies a document. |
Sandi Mitchell | J P Systems, Inc. | ||
| 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 Service Start Date | Date on which services began. |
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. |
Payment member explanation | Payment explanation to a member on an EOB |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Cancer Care | Radiation Therapy Course Target Dose Volume | Radiation dose delivered to the target volume in fulfilling the prescription (e.g. 7200 cGy). |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Custodian | The custodian is the organization that is in charge of maintaining and is entrusted with the care of the document. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Cancer Care | Radiation Therapy Course Target Dose Unit | Unit corresponding to numerical value of radiation dose (e.g. cGy) |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Diagnostic Imaging | Tests that result in visual images requiring interpretation by a credentialed professional. |
Imaging studies performed | The indication of an imaging diagnostic studies performed (with type) and completed on patients, including DEXA, mammography, bone scans |
LOINC (i.e. OID: 2.16.840.1.113883.3.526.3.320) HCPCS |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Category | AMIA recommends a more thorough breakdown of the Medical Devices Data Class. For medical devices, there should be a distinguishment between permanent versus temporary data classes. Temporary devices for example PICC line, indwelling foley and suprapubic catheters, and wound vacs. Medical applications should also be included as they are considered medical digital devices, such as digital therapeutics, standard languages, payor exchanges, what is included and excluded in this category. |
FDA Unique Device Identification (UDI) System |
Tayler Williams | American Medical Informatics Association (AMIA) |