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 1 | Security Label | Security Label Purpose of Use (POU) Tag | A POU tag is the 0..* component of a Security Label that conforms to follows the HL7 Healthcare Privacy and Security Classification System (HCS), Release 1 syntax to indicate the circumstances under which an authorized recipient is permitted to perform an activity such as create, collect, access, use, or disclose. For HL7 POU codes, see POU value set at: https://build.fhir.org/ig/HL7/UTG/ValueSet-v3-PurposeOfUse.html We recommend creating a value set of POU codes to value the POU tag, which are specific to priority US policies as discussed in the HL7 Cross-Paradigm US Regulatory Security Labeling Implementation Guide, which is under development. |
HL7 v3 code systems and value sets, and HL7 standards listed in the Data Elements above, and discussed in the use cases. All be the Cross Paradigm for US Regulatory Security Labeling, FHIR US Regulatory Security Labeling IG, and the FHIR DS4P IG are normative. |
TICIA Louise GERBER | Health Level Seven International | ||
| Level 1 | Advance Directives | Durable Medical Power of Attorney | A person uses a durable medical power of attorney to appoint one or more people to serve as advocates or “healthcare agents” empowered to make medical treatment decisions on behalf of that person if the person is incapacitated and cannot communicate with medical personnel. |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | Advance Directives | Living Will | In a living will, a person specifies whether he or she wants (or does not want) “life-sustaining treatments” (e.g., artificial nutrition or hydration, dialysis or the use of a ventilator to help with breathing), external cardiac compression (CPR), the application of an electric current to the heart (defibrillation), or the use of a tube placed into the windpipe through the mouth or nose to help the person breathe, should that person suffer a medical emergency and be unable to communicate with the care team. A living will includes information that helps the healthcare agent make treatment decisions on the person’s behalf, and is used by medical professionals to inform their treatment plans. |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | Advance Directives | Quality of Life Priorities | A PACP may contain a person’s quality of life priorities based on their personal values for what is important to them in order to have a good quality of life. They may value such things as being able to take care of themselves without needing physical help from loved ones, or being able to live without depending on machines to keep them alive, or living as long as possible by receiving all the medical care doctors believe will help them. The intent of the quality of life priorities is to provide guidance to the future care team, in a situation where the person is unable to communicate for his or her self, that informs their healthcare agent as to what is important to them and provides guidance to the care team when treatment decisions need to be made on the person’s behalf. |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | Work Information | Employment Status | This data element includes a coded concept, Employment Status, with time and date stamp and/or start date and end date. A person can be both employed and retired, and can have a different employment status for each job. Employment Status is a person's self-reported, coded relationship to working for pay, family earnings, or training (e.g. having one or more jobs, searching for work, etc.). A person’s Employment Status is independent of Job characteristics, e.g., not “full-time work” or “part-time work,” because many people have more than one job. |
An information model of the Patient Work data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation. Logical Observation Identifiers Names and Codes (LOINC; https://loinc.org/) codes are available for each Patient Work Data Element, including Employment Status. The ODH code set (https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.327) provides a value set for Employment Status as well as other Patient Work Data Elements (https://phinvads.cdc.gov/vads/SearchValueSets_search.action?searchOptions.searchText=ODH). The PHIN VADS ODH Hot Topics section provides downloadable files with Preferred Concept Names and Easy Read Descriptions for Employment Status values (https://phinvads.cdc.gov/vads/SearchVocab.action). Interoperability standard formats for all of the Patient Work Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References: HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/ HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516 . Chapter 2C, Tables, Tables 0954-0959 provide the Patient Work Data Element component value sets. Chapter 3, Patient Administration, sections 3.4.15 and 3.4.18 describe the Patient Work Data Elements Employment Status and Combat Zone Period as Occupational Health (OH) segments; Retirement Date is included in the PD-1 segment. |
Genevieve Luensman | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health | ||
| Level 1 | Advance Directives | Personal Advance Care Plan | Advance care plan is a general term for any documentation or other recordation of a person’s medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. An advance care plan places an emphasis on communication, as opposed to legal formalities. A PACP is a term specifically defined by HL7 as a template to facilitate the sharing of information expressed in advance care plans. A PACP may include the type of information contained in a living will and/or a durable medical power of attorney, and it also may include other medical interventions experience preference and instructions that help a healthcare agent make treatment decisions on the person’s behalf, and can be used by medical professionals to inform their medical interventions and treatment planning for the patient. Within the family of documents that have been defined under Consolidated CDA, the PACP document can be classified as a type of patient-generated document. The PACP document facilitates digital exchange of information previously and currently captured and shared using paper documents. Digital exchange of this type of data has become particularly critical within the context of COVID-19. To reduce the spread of disease, hospitals have disallowed patient family members and/or representatives to be present when the patient is admitted and as medical interventions are rendered, while also prohibiting acceptance of paper documents due to concerns of contagion. A PACP may include information relating to the appointment of a healthcare agent and alternate agents and establishing their authorized powers and limitations. It also may include information relating to any or all of the following: goals, preferences, and priorities for medical interventions (e.g., palliative and/or hospice care), including medical treatment preferences, based on the patient’s individual values, spiritual and religious beliefs, and personal definitions of quality of life; instructions to be followed after death (e.g., organ donation and autopsy); and information about who has signed, witnessed, and notarized the information authored by the individual, if available and appropriate. The set of recognized kinds of advance directive documents include concepts from the value set: Advance Directives Categories urn:oid:2.16.840.1.113883.11.20.9.69.4 which is openly available for reference in the National Library of Medicine’s Value Set Authority Center. It can be referenced using this url: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.69.4/definition |
HL7 CDA® R2 Implementation Guide: Personal Advance Care Plan (PACP) Document, Release 1 - US Realm STU Release 2 The PACP document is a CDA document template designed to share information created by an individual to express his or her care and medical treatment goals, preferences, and priorities for some future point in time, under certain circumstances when the individual cannot make medical treatment decisions or communicate his or her goals, preferences, and priorities with the care team. The purpose of the PACP document is to ensure that the information created by the individual is available and considered in clinical care planning, and the focus of the standard is sharing patient generated information. It should not matter if the source information is documented on a piece of paper, in a video recording, or in a consumer-controlled application that exists for this purpose. The standard provides a means to share this information in a standard way with a system that maintains a clinical record for the person. It is not intended to be a legal document or a digitization of a legal document. However, a PACP can reference a legal document, and it can represent information contained in a legal document such as the appointment of healthcare agents and the identity of witnesses or a notary. |
Matt Elrod on behalf of ADVault, Inc. | ADVault, Inc. | ||
| Level 1 | 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. |
PROMIS (Patient-Reported Outcomes Measurement Information System) survey score result | Patient-Reported Outcomes Measurement Information System (PROMIS) program created new paradigms for how clinical research information is collected, used, and reported. PROMIS addressed a need in the clinical research community for a rigorously tested patient reported outcome (PRO) measurement tool that uses recent advances in information technology, psychometrics, and qualitative, cognitive, and health survey research to measure PROs such as pain, fatigue, physical functioning, emotional distress, and social role participation that have a major impact on quality-of-life across a variety of chronic diseases. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | Work Information | Retirement Date | Retirement Date is a self-reported date (at least year) that a person considers themselves to have ‘retired’. A person can have more than one Retirement Date. A person can be both employed and retired, so these data are independent of one another. |
An information model of the Work Information data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation. Logical Observation Identifiers Names and Codes (LOINC) codes are available for each Work Information Data Element and each component of the data elements, including Retirement Date (https://loinc.org/). Interoperability standard formats for all of the Work Information Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References: HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/ HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516. Chapter 3, Patient Administration: Retirement Date is included in the PD-1 segment. |
Genevieve Luensman PhD | Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH) | ||
| Level 1 | 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. |
Promise Preference (PROPr) Utility Score | PROPr is a score for the PROMIS measurement system. PROPr combines scores from 7 PROMIS domains into a single preference-based score (also called a health utility score). This score captures the preferences of the general adult US population. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | 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. |
Two-item PROMIS®️ global physical and mental health scales | Two-item PROMIS®️ global physical and mental health scales: Global health items provide synoptic information that can be utilized as predictive indictors of health care utilization and mortality. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | |
| Level 1 | Cancer Care | NCI Patient Reported Outcomes (PRO)-Common Terminology for Criteria for Adverse Events (CTCAE) | PRO-CTCAE (NCI Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events) was developed to evaluate symptomatic toxicities by self-report in adults, adolescents and children participating in cancer clinical trials. It is designed to be utilized in comparison to the Common Terminology Criteria for Adverse Events (CTCAE), the standard lexicon for adverse event reporting in cancer trials. |
ICD-10 : https://www.cms.gov/Medicare/Coding/ICD10 |
Kevin Jung | University of California San Francisco Breast Care Center | ||
| Level 1 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Administration Patient | The person who received the administered medication. While seemingly self-evident as a part of an administration record, the requirement of the patient being linked to the drug administered is critical (assuming Medication Administrations become part of USCDI |
In FHIR R4, https://www.hl7.org/fhir/medicationadministration-definitions.html#Medi… |
Scott Gordon | Food and Drug Administration | |
| Level 1 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Patient Birth Place | The city, state, county and country or location in which the patient was born. |
FHIR patient extension: birthplace FHIR patient address.period |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 1 | Facility Information | Physical place of available services or resources. |
Facility GPS Coordinates | Various: FHIR DSTU2, 3 and 4, CDA Release 2.0, HL7 V2 PL Data Type |
Keith W. Boone | Audacious Inquiry | ||
| Level 1 | Genomics | Variant Type | The data representing the type of genetic variation. Some examples of variant types include DNA, protein, chromosome. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Genomics | Variant Interpretation | The categorical or clinical assessment of the genetic variant data, where interpretation is necessary to fully understand the significance. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Genomics | Variant Data | The data representing the genetic variant information itself. Depending on the type of genetic variation, this data element could contain representation of a genomic DNA change, amino acid change, etc. |
* SNOMED CT LINKS: SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Genomics | Gene Studied | The human gene targeted for mutation/variant analysis. |
SNOMED CT LOINC HGNC Notation HGVS Nomenclature COSMIC ISCN |
Steve Bratt | CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator | ||
| Level 1 | Exposure/Contact Information | Exposure/Contact Source/Target Participant | The source or target of the exposure or contact. Could be person, animal, or location. Either the patient's contact with an entity (person, animal, or substance) or presence at a location where exposure to an agent could have occurred or the patient's contact with an entity (person, animal, or substance) or presence at a location where transmission from the patient could have occurred. | HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: US Public Health Exposure Contact Information profile (Observation.component) HL7 CDA: Exposure/Contact Information Observation template (observation/participant) |
Laura Conn | |||
| Level 1 | Exposure/Contact Information | Exposure/Contact Direction | Whether the direction of exposure/contact is acquisition (patient is the target and another person, animal, location, etc. is the source) or transmission (patient is the source and another person, animal, location, etc. is the target). | HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) based on FHIR R4 HL7 CDA® R2 Implementation Guide: Public Health Case Report - the Electronic Initial Case Report (eICR) HL7 FHIR: US Public Health Exposure Contact Information profile (Observation.component) HL7 CDA: Exposure/Contact Information Observation template (observation/participant) |
Laura Conn |