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 | Cancer Care | Radiation Therapy Prescription Name of Radiation Therapy Prescription | Name of the radiation therapy prescription used to distinguish it from other prescriptions. |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Nutrition and Diet | Oral Diet Fluid Consistency | The required consistency of fluids and liquids provided to improve safety for patients with swallowing difficulties. For example, “moderately thick” or “thin”. The ISDDI Framework (https://iddsi.org/Framework) for drinks is recommended as the terminology for this data element. |
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 | 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) | |
| 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 | 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 | 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 End Date | Date on which services ended. |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| 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. |
Accommodation | Provides information or details regarding modifications, tools, technologies, and/or other supports needed in order to address any barriers to care that an individual living with a disability(ies) may need in order to improve their care and life with a diagnosis. |
Grace Cordovano | Enlightening Results | ||
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator set positive end expiratory pressure | The set positive end expiratory pressure (PEEP) if the patient is receiving mechanical ventilation or a biphasic positive airway pressure. |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator pressure support | The pressure support above PEEP if the patient is receiving mechanical ventilation |
Airway type LOINC LL5542-7 |
Ali Abbasi MD- on behalf of the I-SPY COVID investigators | I-SPY COVID Trial Investigators | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Cause of Death | Cause of death information includes the sequence of events leading to death as well as other conditions significantly contributing to death. The underlying cause of death may be different than the terminal condition. This may include summary of death note, and/or death information that may be captured within the discharge summary note or other cause of death documentation within the clinical notes section. |
LOINC: Summary of death note: 47046-8: https://loinc.org/47046-8/ Physician Summary of death note: 83796-3: https://loinc.org/83796-3/ Nurse Summary of death note: 84273-2: https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Supporting Links: PHINVADS Value Set: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3593 |
Maria Michaels | CDC | |
| Level 0 | Nutrition and Diet | Oral Diet Texture Modifiers | Texture modifications to indicate how to alter the texture of foods to improve safety for patients with swallowing difficulties. For example, “pureed” or “soft & bite-sized”. The ISDDI Framework (https://iddsi.org/Framework) for foods is recommended as the terminology for this data element. | 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 | Pathology Molecular Test Name | Name of the molecular pathology test used as part of diagnosis and staging. There are a wide range of tests. In the case of prostate cancer values include: |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan | ||
| Level 0 | Cancer Care | Pathology Molecular Test Result | Score for the molecular test result identified. For example Pathology Molecular Test Name is ProMark, Result could be 30 |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan | ||
| Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Specimen Collection Method | This is the collection method of the specimen sent for laboratory testing. |
SNOMED CT® |
Sanjeev Tandon on behalf of CDC | CDC | |
| Level 0 | Cancer Care | Radiation Therapy Course Target Dose Volume | Identify targets and overall doses treated with the radiation therapy course. This supports systematic reporting what was done for treatment summaries. For example it enables identifying that the prostate received a dose of 7200 cGy. Where the prescription reflects intent, this element reflects what was delivered. |
Elizabeth Covington | University of Michigan | |||
| Level 0 | Cancer Care | Radiation Therapy Course Target Dose Volume | Name of target volume structure for radiation therapy (e.g. Prostate). |
Elizabeth Covington | University of Michigan | |||
| 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Genetic Testing | Narrative clinical assessment of the Genetic Testing results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA |