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 | 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 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
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Airway Management | Patient history and assessments performed by healthcare providers which are used to identify airway management techniques used and potential complications. These elements are important for any patients undergoing airway management, whether in the emergency department, in the intensive care unit, or in the operating room for elective or emergent surgical procedures with anesthesia. |
Difficult tracheal intubation: Difficult mask ventilation: Mallampati scores: Video intubation: (glidescope) Intubation techniques: Difficult supraglottic airway ventilation |
Matthew Popovich | American Society of Anesthesiologists | |
| 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. |
Terminal Illness Status | Recommended to have element for Terminal Illness Status in this Data Class in USCDI V3. This is a matter of interest to Next of Kin/Related Parties and of high value to Care Team (needed for revised Care Plan) and would immensely help with timely and seamless Transition and Coordination of Care between different settings and care givers. |
Terminal illness (Code 300936002) SNOMED code. https://www.hipaaspace.com/medical_billing/coding/snomed/300936002 https://www.findacode.com/snomed/162607003--terminal-illness-early-stag… https://build.fhir.org/ig/cqframework/opioid-cds-r4/ValueSet-limited-li… |
Dave Shekhar | ||
| Level 1 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Maternal Social Determinants of Health Note | The Maternal Social Determinants of Health Note supports the aggregation of significant events, social problems and related health concerns, and plans of care derived from the visits over the course of a maternal care episode. It is a summary of the most critical information maternal care providers capture and share regarding the status of a maternal patient's social issues. The information is aggregated data from which the patient’s interactions with healthcare and social services providers are captured. |
SNOMED CT LOINC ICD10 ICD9 CM ICD10CM, SNOMEDCT |
Andrea Fourquet | IHE USA | |
| Level 1 | Vital Signs | Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions. |
Pain Severity | This element is used to describe how intense or severe the sensation of pain is on a 1-10 scale. |
LOINC: 38208-5 Pain severity – Reported |
Dr Susan A Matney | Intermountain Healthcare | |
| Level 1 | Special Alerts for Care Handoffs | Results LOINC | All pending results and contact information for how to obtain |
ICD 10, SNOMED, LOINC, RxNorm |
Holly Miller, MD | MedAllies | ||
| 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 | Provenance | The metadata, or extra information about data, regarding who created the data and when it was created. |
Author Id | An identifier of the person or device who authored the document. |
Sarah Gaunt | The Association of Public Health Laboratories (APHL) | ||
| Level 1 | Outcomes | Serious Adverse Events | An adverse event is any undesirable experience associated with the use of a medical product in a patient. |
SNOMED CT |
Mitra Rocca | Food and Drug Administration | ||
| 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 0 | Referral | Referral requestor | The individual who initiated the request and has responsibility for its activation. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Pregnancy Information | Number Fetal Deaths This Delivery | The number of fetal deaths in this delivery. |
LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive |
Craig Newman | Altarum | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Multiple Birth Order | If not a single birth then the order born in the delivery, live born or fetal death (1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.). |
FHIR patient extension: birthplace FHIR patient address.period |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | |
| Level 0 | Referral | Referral coverage | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Referral | Referral code | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. |
Routine Interfacility Patient Transport (RIPT) - https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_RIPT.pdf https://hl7.org/fhir/R4/servicerequest.html |
Adam Bazer, MPD | Integrating the Healthcare Enterprise USA (IHE USA) | ||
| Level 0 | Substance Use | Ethanol in blood | This data element includes the mass/volume of ethanol present in blood |
Most of the requested data elements are in LOINC, as per the codes below. We have requested the addition of the NIAAA Single-Item Screener and the diagnosis of Alcohol Use Disorder to LOINC. AUDIT-C : 72109-2 Ethanol in blood: 5640-8 Ever drink alcohol: 69721-9 Average daily alcohol intake: 74013-4 Alcohol binge episodes/month: 11286-2 Alcohol abuse or dependence: 74043-1 Alcohol help during pregnancy: 64718-0 |
Laura Kwako | National Institute on Alcohol Abuse and Alcoholism | ||
| Level 0 | Patient Demographics/Information | Data used to categorize individuals for identification, records matching, and other purposes. |
Medical Record Number | The unique identifier assigned by the provider to reference a single patient |
Structural standards exist for the capture and exchange of MRNs and are part of all EHRs and standard transaction. However, there is no global assignment of an identifier to an individual patient. |
Mark Roberts | Leavitt Partners | |
| Level 0 | Allergies and Intolerances | Harmful or undesired physiological responses associated with exposure to a substance. |
Food Allergy Intolerance | Common food substances and allergens that can cause harmful or undesirable physioloical responses when exposed to the substance or the substance is consumed. |
SNOMED CT with a value set created in VSAC (OID: 2.16.840.1.113762.1.4.1186.3) HL7 Cross Paradigm Specification: Allergy and Intolerance Substance Value Set(s) Definition: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=482 was used to create the value set |
Becky Gradl | Academy of Nutrition and Dietetics | |
| Level 0 | Outcomes | Actuality | Did the event (harm) occur or is there potential for harm – ie. Actual, potential |
HL7.org FHIR R4 v4.0 |
Sandi Mitchell | J P Systems, Inc. | ||
| 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. |
Pain Assessment | An assessment of a person’s pain, which could include assessment of acute and chronic pain using standardized assessment tools. Assessments of pain include but not limited to pain severity, interference of pain on activity, and pain impact on mood or sleep using unidimensional or multidimensional assessment tools. | LOINC and SNOMED CT |