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 - Mobility | 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: “Do you have serious difficulty walking or climbing stairs?” 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Outpatient Note | Documentation of a clinical encounter that takes place in an outpatient setting. Reason to consider separately (including this here because the "Reason" field for additional elements is truncating my text): This data element has some overlap with other existing and proposed Clinical Notes data elements Outpatient is a setting versus a type of service (Consultation, History & Physical, Discharge Summary, Transfer Summary, etc.). For example, Outpatient consultation notes span the “Consultation Note” and “Outpatient Note” data elements. However, we feel it is important to specify this particular setting because the vast majority of LOINC terms representing outpatient clinical notes aren’t captured in the data elements that represent particular types of service. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual Fields | Narrative clinical assessment of the Visual Fields evaluation. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| Level 0 | Social Determinants of Health | Education Level | 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 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 |
Charles Mayo | University of Michigan | ||
| Level 0 | Substance Use | Secondhand Smoke Exposure | Assessment of a patient’s exposure to smoke emitted from tobacco products used by others. |
Exposure to Second Hand Tobacco Smoke: SNOMED 16090371000119103 History of Exposure to Second Hand Tobacco Smoke: SNOMED 699009004 No Known Exposure to Second Hand Tobacco Smoke: SNOMMED 711563001 Second hand smoke exposure CPHS (Children’s preventive health services) LOINC: 39243-1 |
Nedra Y Garrett | CDC | ||
| Level 0 | Cancer Care | Mode of Diagnosis | The diagnosis specifies a patient’s concern/problem after a series of diagnostic tests and screening procedures by the healthcare provider. Beyond the encounter diagnosis (existing USCDI data element), the Encounter Information should include the mode of diagnosis. The key to cancer treatment is the type of tumor and the encounter data must include how the diagnosis was assessed as well as the critical features on pathology (including modern molecular tumor profiling). |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | ||
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Ventilator set tidal volume | The tidal volume set on the ventilator 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.
|
Telehealth note | Documentation of a clinical encounter that takes place via telehealth. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Nutrition and Diet | Enteral Nutrition Frequency | Scheduled frequency of enteral 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 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Oxygen Delivery Device | Specification of the method of oxygen delivery. Usage note: Provides critical context to understanding a patient's respiratory status, especially in light of the COVID-19 pandemic which predominantly causes illness with pneumonia. Examples include but are not limited to nasal cannula, face mask, non-rebreather, BIPAP, CPAP, and ventilator. This would provide critical additional context to understanding a patient's respiratory status, especially in light of the COVID-19 pandemic which predominantly causes illness with pneumonia. |
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Joshua D. Geleris, MD | Columbia University Irving Medical Center | |
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Report Submission Date/Time | The date and time at which the EHR system sends the report. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Report Date | The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.), completes collection of data for the report. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Pregnancy History for Death Certificate | Data elements or description that provide a woman's pregnancy history at the time of death. |
"LOINC: Summary of death note: 47046-8 Physician Summary of death note: 83796-3 Nurse Summary of death note: 84273-2 US Standard Certificate of Death Hepatitis C Case Report Form "LOINC Codes for death note summaries: https://loinc.org/47046-8/ https://loinc.org/83796-3/ https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Pregnancy History - While a one to one relationship may not exist between the information in the EHR and what is needed in a state's electronic death registration system (EDRS), the information in the EHR (even if available in longhand), can help inform filling out the following in the EDRS. IF FEMALE: □ Not pregnant within the past year □ Pregnant at the time of death □ Not pregnant, but pregnant within 42 days of death □ Not pregnant, but pregnant 43 days to 1 year before death □ Unknown if pregnant within the past year Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf" |
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 Denial Code | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider |
NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Colonoscopy | Narrative clinical assessment of the Colonoscopy results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
EKG/ECG Tracing Image | Narrative interpretation of the EKG/ECG Tracing Image. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Endoscopy | Narrative clinical assessment of the Endoscopy results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Myelogram | Narrative clinical assessment of the Myelogram results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
| Level 0 | Nutrition and Diet | Enteral Nutrition Additive | Type of modular component to add to the enteral nutrition 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Clinical Notes for Newborn | "Clinical notes information for a newborn may include the Labor and delivery summary record under–Infant data, and maternal progress note. Example information will include breastfeeding information at time of discharge." |
"LOINC codes exist for each of the proposed data elements The clinical notes of an new born should capture information such as: 73756-9 | Infant is being breastfed at discharge" |
Nedra Garrett | Centers for Disease Control and Prevention |