USCDI Export for the Public

Self-Identified Need for Contraception screening tool for primary care settings.

Self-Identified Need for Contraception (SINC) LOINC: 98076-3
Example answer list:
Yes (qualifier value) LA33-6
No - I do not want to talk about contraception today because I am here for something else; LA32389-1
No - This question does not apply to me/I prefer not to answer; LA32390-9
No - I am already using contraception; LA32393-3
No - I am unsure or don't want to use contraception; LA32391-7
No - I am hoping to become pregnant in the near future; LA32392-5

Cause of death information includes the sequence of events leading to death as well as other conditions significantly contributing to death. The underlying cause of death may be different than the terminal condition. This may include summary of death note, and/or death information that may be captured within the discharge summary note or other cause of death documentation within the clinical notes section.

LOINC: Summary of death note: 47046-8: https://loinc.org/47046-8/ Physician Summary of death note: 83796-3: https://loinc.org/83796-3/ Nurse Summary of death note: 84273-2: https://loinc.org/84273-2/ US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/DEATH11-03final-ACC.pdf Hepatitis C Case Report Form: https://www.cdc.gov/hepatitis/pdfs/HepatitisCaseRprtForm.pdf Supporting Links: PHINVADS Value Set: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3593

The indication of an imaging diagnostic studies performed (with type) and completed on patients, including DEXA, mammography, bone scans

LOINC (i.e. OID: 2.16.840.1.113883.3.526.3.320) HCPCS

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

The way a tumor acts within the body, e.g., ability to grow, invade other areas and/or metastasize.

Tumor Histologic Type: International Classification of Diseases for Oncology 3.2, with additional values accepted by the WHO-IARC but not included in the official published documents. SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, 2021 Release (month TBD) Tumor Behavior: International Classification of Diseases for Oncology 3.2 Tumor Primary Site: International Classification of Diseases for Oncology 3.2. SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release Tumor Laterality: SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release – mCODE Laterality Value Set Tumor Clinical Grade: North American Association of Central Cancer Registries Grade Clinical

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.

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

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
LOINC:86645-9
Example answer list:
Answer
Yes, I want to become pregnant; LA26438-4
I'm OK either way; LA26439-2
No, I don't want to become pregnant; LA26440-0
Unsure; LA14072-5

SNOMEDCT response option value set OID: 2.16.840.1.113762.1.4.1166.22

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

Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide
https://confluence.hl7.org/display/PHWG/Diagnostic+Audiology+Reporting+…
Subset of this implementation guide that = Audiogram is
•Diagnostic audiology tests performed
•Results of the diagnostic evaluation: left ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of the diagnostic evaluation: right ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of diagnostic evaluation in the form of audiogram

A tribe of which the patient is an enrolled member.

HL7 FHIR: US Public Health Tribal Affiliation extension
HL7 CDA: Tribal Affiliation template
HL7 Value Set: TribalEntityUS

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

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

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

Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable.

Military service in the armed forces of the United States or other nations, including the length and branch of service, the military occupation, the location and type of duty (e.g., in the United States or abroad with combat, combat support, or noncombat duties), and any ongoing illness, injury, limitation, or disability that began during military service. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 297 (2014).)

Yes, a vocabulary/terminology standard and/or technical specification exists for each proposed data element. The Gravity Project attaches a letter with an overview. For (1) Food Insecurity: LOINC, SNOMED-CT, ICD-10-CM, and CPT/HCPCS terminologies are specified by value set in NLM’s Value Set Authority Center (VSAC). For (2) Housing Instability and Homelessness, (3) Inadequate Housing, (4) Transportation Insecurity, (5), Financial Strain, (6) Social Isolation, (7) Stress, (8) Interpersonal Violence, (9) Education, (10) Employment, and (11) Veteran Status: • The corresponding value sets are under development by the Gravity Project; • The value sets will be complete prior to publishing of USCDI v2.0; • Even if a particular value set might be incomplete, the value set will be citable. The technical specifications for value sets under each data element are described below: • Assessments: LOINC • Health Concerns/Problems/Diagnoses: SNOMED-CT, ICD-10-CM • Goals: LOINC • Procedures/Interventions: SNOMED-CT (clinical), CPT/HCPCS (billing) • Outcomes: LOINC (NCQA measures) • Consent (where needed): based on existing HL7 code systems

Treatment Change documents the reason for changes to the plan of treatment plan. The options for this data element are, for example: no change (continue treatment), planned change, no response to treatment, adverse reaction, patient request for alternative treatment. The first option (no change in treatment plan) can document a review of the treatment plan that did not require in a change of treatment.

LOINC, SNOMED-CT, and FHIR see: https://search.loinc.org/searchLOINC/search.zul?query=functional+status http://hl7.org/fhir/us/mcode/ https://browser.ihtsdotools.org/?perspective=full&conceptId1=273472005&edition=MAIN/2020-07-31&release=&languages=en

Disease trend, also referred to as disease status, represents the clinician's overall judgment on the current trend of a condition, e.g., whether it is stable, worsening (progressing), or improving (responding). The judgment may be based a single type or multiple kinds of evidence, such as imaging data, physical examination, tumor measurements, laboratory data, etc. The condition trend can be reported multiple times during the course of a condition, each report representing the clinical judgement at that point in time. The element is important in assessing disease progression and determining the efficacy of treatments.

HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1

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

The unique identifier for a single instance of a specimen received by a laboratory and its analysis.