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 2 | Immunizations | Record of vaccine administration. |
Vaccination Event Record Type | Indicates whether the vaccination event is based on a historical record (e.g., second hand knowledge of the vaccination event) or was administered at the facility submitting the data. |
LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/ PHINVAD Immunization Information Source |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 2 | Travel Information | Travel History Dates | The dates spent in a location traveled to. |
§ SNOMED: 420008001 |Travel (event)| |
Craig Newman | Altarum | ||
| Level 2 | Travel Information | Travel History Location | A location in a person’s travel history either as an address or as a coded location. |
1. SNOMED: 420008001 |Travel (event)| 2. Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) 3. ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) |
Craig Newman | Altarum | ||
| Level 2 | Nutrition and Diet | Oral Diet Type | The name or type of oral diet or diet restrictions that describe what can be consumed orally. For example “general healthful diet”, “consistent carbohydrate diet”, or “renal diet”. |
HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185) 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: |
Becky Gradl | Academy of Nutrition and Dietetics | ||
| Level 2 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Negation Rationale | Medications (including medications with dose): RxNORM Medication Route: SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.222) Negation Rationale (reason codes): SNOMED (i.e. OID: 2.16.840.1.113883.3.117.1.7.1.93) https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm Negation Rationale: https://www.hl7.org/fhir/valueset-reason-medication-not-given-codes.html , http://hl7.org/fhir/us/qicore/ValueSet-qicore-negation-reason.html |
Joel Andress | CMS | ||
| Level 2 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
BMI | LOINC |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | ||
| Level 2 | Organization | Healthcare Services | Describe a specific healthcare service or category of services (such as counseling, imaging, or laboratory) offered by an organization at a designated location, which can be either physical or virtual. The service provider may include hospitals, clinics, pharmacies, or other specialized healthcare providers. |
In addition to LOINC and SNOMED CT, other relevant code systems for the Healthcare Service data element include: 1. NDC (National Drug Code): For identifying medications and drug services. These additional code systems further support the standardized representation of healthcare services. |
Mike Hamidi | Vulcan | ||
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Mother's Maiden Name | Contains information about the patient’s mother’s last name when she was born (i.e., before marriage). |
CDC-defined HL70063 |
Nedra Garrett | Centers for Disease Control and Prevention | |
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Deceased Indicator | Indicates if the individual is deceased or not. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Policy Number | The unique identifier for a specific insurance policy that defines a set of covered benefits and services along with other information that is necessary to administer the policy (e.g. financial obligations for both parties) |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Device used | Devices are an identifiable grouping of mobility devices (i.e., wheelchairs), implantable devices (i.e., pace makers), or other wearable devices (i.e. compression socks or venous foot pump) with significant impact on patient functionality and health. The QDM v5.5 notes that “Device represents an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.” |
SNOMED CT (Frailty Device, value set OID: 2.16.840.1.113883.3.464.1003.118.12.1300) SNOMED CT (Intermittent Pneumatic Compression Devices (IPC), value set OID: 2.16.840.1.113883.3.117.1.7.1.214) SNOMED CT (Graduated Compression Stockings (GSC), value set OID: 2.16.840.1.113883.3.117.1.7.1.256) SNOMED CT (Venous Foot Pumps (VFP), value set OID: 2.16.840.1.113883.3.117.1.7.1.230) SNOMED CT (Cardiac Pacer, value set OID: 2.16.840.1.113883.3.526.3.1193) ICD-10-CM, SNOMED CT (Cardiac Pacer in Situ, value set OID: 2.16.840.1.113883.3.526.3.368) |
Joel Andress | Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ) | |
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Nutrition Order | A clinician (provider)-authored request for a diet, formula feeding (enteral), or nutritional supplement. |
SNOMED CT |
Michelle Ashafa | Academy of Nutrition and Dietetics | |
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Referral Orders | Provider-authored request to another provider, specialist, or organization for care services. Examples include referral orders to a wound specialist or podiatrist. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Identifier | An identifier for the patient |
FHIR US Core |
Sarah Gaunt | Lantana Consulting Group | |
| Level 2 | Orders | Provider-authored request for the delivery of patient care services. Usage notes: Orders convey a provider’s intent to have a service performed on or for a patient, or to give instructions on future care. |
Medical Device Orders | Provider-authored request for medical devices, such as for therapeutic footwear or walking aids. |
SNOMED CT |
Grace Glennon, on behalf of NCQA | NCQA | |
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Coverage Period | The time frame in which the policy is in force. |
Member, subscriber, group, and plan identifiers are assigned by healthcare insurer. The coverage period is a standard date range during which the coverage is in effect. There is currently no standard Healthcare Payer Identifier (e.g. HPID) but frequently the NAIC identifier is used but not required. |
Robert C Dieterle | On behalf of the Da Vinci Project | |
| Level 2 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Medical Device Status | Information beyond the UDI is required for patient care and clinical research. If a patient record is transferred to a new provider, the implant date of all active and inactive devices as well as the explant date of previously implantable devices is relevant. To conduct safety and effectiveness research, implant date, explant date and therapy status are relevant. Proposing implanted/inactivated/reactivated/explanted as the status values and that the status history is included as opposed to only current status. | NCI Thesaurus |
TICIA Louise GERBER | Health Level Seven International | |
| Level 2 | Social History | Sexual Activity | Information on the sexual activity of the patient |
SNOMED CT: (Parent code and all children codes in the hierarchy) 414254005 - Finding of frequency of sexual activity (finding) 162171002 - Currently not sexually active (finding) 228453005 - Sexually active (finding) *LOINC 64728-9 - Have you ever had vaginal intercourse [PhenX] *Note Montana's Department of Public Health and Human Services (DPHHS) includes SNOMED CT codes in their “Adolescent Wellness” Registry, addressing the “STI Screening” measure, together with the “Chlamydia Screening in Women” measure. |
Raymonde Uy | National Association of Community Health Centers (NACHC) | ||
| Level 2 | Health Insurance Information | Data related to an individual’s insurance coverage for health care. |
Payer Name | The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. |
Coverage type and self paid codes; Many of the defined elements in a resource are references to other resources. Using these references, the resources combine to build a web of information about healthcare; ID assigned to the subscriber |
Shelly Spiro | Pharmacy HIT Collaborative | |
| Level 2 | Procedures | Activity performed for or on a patient as part of the provision of care. |
Procedure Status | The status of the procedure (e.g., planned, completed). |
Procedure Code (same as current USCDIv1): Health Care Financing Administration Common Procedure Coding System (HCPCS), as maintained and distributed by HHS. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other health care services. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2019 Release. http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html Optional: International Classification of Diseases ICD-10-PCS 2020. http://www.cms.gov/Medicare/Coding/ICD10/index.html Technology which records dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services. http://www.ada.org/en/publications/cdt Procedure Date: HL7 FHIR Datatypes (dateTime|Period|string|Age|Range) http://hl7.org/fhir/datatypes.html#dateTime http://hl7.org/fhir/datatypes.html#Period http://hl7.org/fhir/datatypes.html#string http://hl7.org/fhir/datatypes.html#Age http://hl7.org/fhir/datatypes.html#Range Procedure Status: HL7 FHIR Event Status (preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown). http://hl7.org/fhir/R4/valueset-event-status.html |
Maria Michaels | CDC |