USCDI Export for the Public

Represents a therapeutic response (as opposed to an undesired reaction) to the administration of a medication.

HL7 FHIR: Therapeutic Medication Response extension HL7 CDA: Therapeutic Medication Response observation LOINC: 67540-5 "Response to medication" VSAC Value Set: Therapeutic Response to Medication

Assessing patients for planned pregnancy information reduces the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, provide education and interventions.

SNOMED CT
169565003 Pregnant - planned (finding)
LOINC
64722-2 Was this a planned pregnancy [PhenX]
Answer:
Yes LA33-6
No LA32-8

The Estimated Due Date that has been corrected during the period before birth.

LOINC 57060-6 Estimated date of delivery Narrative 11778-8 Delivery date Estimated 53692-0 Delivery date Estimated from conception date 11780-4 Delivery date Estimated from ovulation date 57063-0 Delivery date Estimated from quickening date 90368-2 Delivery date Estimated from physical exam 57064-8 Delivery date Estimated from date fundal height reaches umb 11779-6 Delivery date Estimated from last menstrual period 53694-6 Delivery date Estimated from prior gestational age assessment SNOMED CT 161714006 | Estimated date of delivery (observable entity) 289206005 | Estimated date of delivery from last period (observable entity) 33714007 | Corrected (qualifier value)

Multiple gestation is pregnancy with more than one baby at a time. Examples include pregnancy with twins, triplets, and quadruplets. Multiple gestation is a type of high-risk pregnancy that occurs in approximately three percent of pregnancies.

SNOMED CT 16356006 Multiple pregnancy (disorder) LOINC 45371-2 Multiple pregnancy

The Eastern Cooperative Oncology Group (ECOG) Performance Status represents the patient's functional status and is used to determine how a disease impacts a patient’s daily living abilities and their overall ability to tolerate therapies in serious illness, specifically for chemotherapy.

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

"The estimated gestational age (in weeks, or weeks and fraction of week) of the pregnancy at the time of the health care encounter (in contrast to the gestational age at birth), beginning from the time of fertilization. Needs to be correlated with the date the gestational age was documented. Gestational age (written with both weeks and days) is calculated using the best obstetrical estimated delivery date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date))/ 7"

https://www.hl7.org/implement/standards/product_brief.cfm?product_id=494

 response to therapy – minimal residual disease, complete pathologic response)- local recurrence, distant recurrence

Represents a location in a person’s travel plans (either an address or a coded location).

§ SNOMED: 420008001 |Travel (event)| § Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.do 11.3201) § ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html) § NCI_Thesaurus 22.08e: code C173619 § LOINC v2.72 code: PhenX measure - international travel history:-:Pt:^Patient:-:PhenX (Code 62887-5)

Dates planned for travel to a location.

Geographical location history (https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3201) ISO 3166 country codes (https://www.iso.org/iso-3166-country-codes.html)

The date the vaccination event occurred.

LOINC:30952-6- Date and time of vaccination: https://loinc.org/30952-6/

complications (serious- hospitalization, death)

Indicates the reason the immunization event was not performed.

Immunization Code: CVX: Vaccines Administered 2.16.840.1.113762.1.4.1010.6: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1010.6/expansion Immunization Code: National Drug Codes (NDC): http://www2a.cdc.gov/vaccines/iis/iisstandards/ndc_tableaccess.asp Immunization Status: FHIR Immunization Status Codes: http://hl7.org/fhir/ValueSet/immunization-status Immunization Administered Date: FHIR datatypes: dateTime, String: https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-immunization-definitions.html#Immunization.occurrence[x] Reason Immunization Not Performed: FHIR Immunization Status Reason Codes: http://hl7.org/fhir/R4/valueset-immunization-status-reason.html

The following value should be used to document patient consent during a disaster or pandemic in Texas: TXD – Disaster consent In Texas, there is legislation that requires health care providers to report antiviral, immunization or other medications (AIM) administered to patients in response to a disaster such as COVID-19. When the AIM information is reported the TX IIS (ImmTrac) flags the information as disaster-related. If the patient signs the disaster-related consent form, their personal and disaster related AIMs are stored for the patient’s lifetime. If the patient does not sign the disaster related consent form or the regular, applicable consent form but receives a disaster related AIM, then their personal information and disaster related AIMs are stored in Texas’ IIS for up to 5 years after the end of the disaster. It is crucial for Electronic Health Records to capture, store, and exchange information regarding whether the patient received an AIM that was administered in response a disaster/pandemic so that this information can be shared with others to ensure appropriate medications are delivered and patient health can be maximized..

This element will document the patient’s consent for participating in the Texas statewide immunization information system (IIS). Under state statute, the Texas immunization registry is opt-in.. The following are the different values Texas currently uses to desctibe a patient’s consent status: TXA - Consented Adult, >=18 years old TXY - Consented ImmTrac Child, <18 years of age TXR - First Responder, >=18 years old TXF - Adult Family Member of a First Responder, >=18 years old TXM - Minor Family Member of a First Responder, <18 years old - no consent is on file. After the first initial consent is sent to the registry, the EHR vendor would need to be able to leave the field blank when the patient's information is sent again to the registry.

This variable contains the date consent was obtained or changed. When a provider queries ImmTrac for a patient and a patient who has already consented is found, the query will return the Texas IIS Consent Date stored in the registry. The provider, at the patient’s (or parent/guardian’s direction, as appropriate) can change the consent status. If there is a change, the updated Texas IIS Consent Date should be submitted to the IIS. Texas IIS Consent Date should be stored in date format: YYYYMMDD.

A subjective state that arises when an individual recognizes a situation as threatening, but dealing with the threat requires more resources than the individual has available. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 76 (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

The knowledge and skills gained through education, the credentialing linked to the completion of various levels of schooling, and the quality of education. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 68 (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

Violence between individuals, subdivided into family and intimate partner violence and community violence. (World Health Organization, World Report on Violence and Health, p. 6 (2002).)

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

Working in a job or occupation, and the type and conditions of employment. (Institute of Medicine, Capturing Social and Behavioral Domains in Electronic Health Records, Phase 2, p. 70 (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

An objective lack of social contact with others. (National Academies of Sciences, Engineering, and Medicine, Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System, p. xi (2020).)

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