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 | Exposure/Contact Information | Exposure/Contact Type | The type of exposure/contact (environmental, activity, event, location, person, animal, etc.) to an agent. | 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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Treatment Intent | The purpose of a treatment, or the desired effect or outcome resulting from the treatment. For example, a treatment may be intended to completely or partially eradicate a disease process by disrupting its underlying physiological processes, resulting in improvement in health; or a treatment may have no expectation of eradication but rather may be intended simply to delay the onset of more severe symptoms; or may be intended to prolong life without any expectation of cure. NOTE: Treatment Intent has also been submitted under the Procedures data class |
SNOMED CT codes for therapeutic intent (qualifier value) |
Andre Quina | MITRE | |
| 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 | 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 | 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 | |||
| Level 1 | Work Information | Combat Zone Period | This data element is the self-reported date range(s) when a person worked in what is considered a combat zone. Both civilian workers, such as Department of Defense contractors, and military service members could have worked in combat zones. |
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 | Exposure/Contact Information | Exposure/Contact Date | The date or period on which the possible exposure/contact 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 agent | The possible agent of concern in the exposure/contact. | 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 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Module | The medication module is concerned with resources and functionality in 3 main domains: (1) the ordering, dispensing, administration of medications and recording statements of medication use, (2) Recording of Immunizations given (or not given), evaluation of given immunizations and recommendations for an individual patient at a point in time, and (3) The creation or querying for medications as part of drug information or drug knowledge. https://www.hl7.org/fhir/medications-module.html |
RxNorm and SNOMED CT |
Shelly Spiro | Pharmacy HIT Collaborative | |
| 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 0 | Travel Information | Transportation Details | Information about transportation details such as the type of transport along with any associated information (e.g., name of cruise ship, flight number, airport, seat number, cabin number). |
HL7 FHIR: US Public Health Transportation Details profile HL7 CDA: Transportation Details Organizer/Transportation Details Observation templates VSAC Value Set: Transport vehicle type |
Nedra Garrett | CDC | ||
| 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. |
Sleep Log /Diary | A patient with a sleep problem will often be asked to keep a Sleep Log or Diary , record of sleep behaviors usually including sleep time. wake time, sleep duration, frequency and duration of sleep interruptions, medications, perceived sleep quality, caffeine intake, etc. |
SNOMED CT, ICD-10/11 and HL7 all contain terminologies that cover Sleep Health. International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019) https://www.nlm.nih.gov/healthit/snomedct/index.html https://icd.who.int/en https://www.hl7.org/fhir/terminologies-systems.html |
Christopher M. Miller, MD | National Heart Lung and Blood Institute, NIH | |
| Level 0 | Pregnancy Information | Pregnancy Intention Screening | Screening patient for their desire to become pregnant in the next 12 months in order to determine which reproductive health services may be relevant to offer the patient in that encounter. |
Pregnancy Intention Screening Question: Pregnancy intention in the next year - Reported SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22 |
Emily Decker | Upstream USA | ||
| Level 0 | Travel Information | Purpose of Travel | Purpose of travel (business, tourism, etc.) |
HL7 FHIR: US Public Health Travel History profile (Observation.component) HL7 CDA: Purpose of Travel Observation template SNOMED: 280147009 "Travel Purpose" PHIN VADS Value Set: PHVS_TravelPurpose_CDC |
Nedra Garrett | CDC | ||
| Level 0 | Medical Devices | An instrument, machine, appliance, implant, software or other article intended to be used for a medical purpose. |
Unique Mobile Health Application Identifier (UMHAI) | This is a unique identifier that uniquely identifies mobile health application instance as installed on a mobile device. Related data elements would include Application name, App Builder, version, build number, hosting device, unique identifiers [similar to a Vehicle Identification Number (VIN) used to track and identify individual vehicle]. Unique Mobile Health Application Identifier enables identification of application instance to facilitate recall, maintenance, transparency and traceability. |
Gora Datta | CAL2CAL | ||
| 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 | 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 | 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 | Nutrition and Diet | Enteral Nutrition Rate | Speed with which the enteral formula is provided per period of time. 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.
|
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 |