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 0 | Work Information | Usual Industry | A self-reported term that identifies the kind of business, i.e., primary business activity, in which a person has worked for the longest time while in their Usual Occupation. For a military position, this is the self-reported branch of service. If an appropriate term is not available (e.g., a new kind of business), then a text entry is used. | Occupational Data for Health (Value Set - Industry NAICS Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7900 Industry CDC Census 2010 http://hl7.org/fhir/us/odh/ValueSet-codesystem-industry-cdc-census-2010.html |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Occupation | A self-reported, coded term for the type of work (paid or unpaid) done by a person for the longest amount of time during his or her life, not including voluntary work (done by choice for the benefit of others without compensation). |
Occupational Data for Health (Value Set - Occupation ONETSOC Detail (ODH)) https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7901 Occupation CDC Census 2010 https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7186 |
Nedra Garrett | CDC | ||
| Level 0 | Work Information | Usual Occupation Duration | The self-reported total of all periods of time (in years) a person has spent in their Usual Occupation as of the date recorded, not including intermittent period(s) when the person was not working in that occupation. It is recorded as an integer to one decimal place. | 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. |
HHS Disability Status - Vision | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Are you blind or do you have serious difficulty seeing, even when wearing glasses?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Work Information | Usual Occupation Start Date | The self-reported year that a person started working in their Usual Occupation. | Nedra Garrett | CDC | |||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Knowledge | The MedicationKnowledge resource is draft and is included for comment purposes. This resource represents information about a medication, for example, details about the medication including interactions, contraindications, cost, regulatory status, administration guidelines, etc. https://www.hl7.org/fhir/medicationknowledge.html |
RxNorm and SNOMED CT |
Shelly Spiro | Pharmacy HIT Collaborative | |
| 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. |
HHS Disability Status - Mobility | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have serious difficulty walking or climbing stairs?” https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
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. |
HHS Disability Status - Independence | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescription Patient | The person who is the intended recipient of the medication. While seemingly self-evident as a part of an prescription record, the requirement of the patient being linked to the drug administered is critical | In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.subject |
Scott Gordon | Food and Drug Administration | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Therapeutic Medication Response | 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 |
Laura Conn | ||
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Medication Prescription Do-Not-Perform | Do-not-perform is an additional Boolean element in HL7 FHIR R4 Medication Request representing the provider’s intent that the prescription NOT be carried forward. If it is assumed that Status will be updated based on this command (ie, status will be changed to “cancelled” then this may be redundant. Alternative is an additional Status of “cancelled-by-provider” |
In FHIR R4, https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.status |
Scott Gordon | Food and Drug Administration | |
| 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. |
HHS Disability Status - Hearing | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Medications | Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease. |
Reported Medication (unique) | “Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record.” (from FHIR R4 MedicationRequest.reported[x]). This would clearly identify a medication that only exists in the data system not as part of any direct data for an original prescription (within the same EHR or across an EHR network, etc) but, instead, via descriptive communication or narrative (verbal, written, etc) by a relevant person (the patient, family, a caregiver, another physician, etc.) This may either be represented as a simple Boolean choice or, additionally, include information of the person and/or nature of the reporting. Additionally, some standards and system implementations provide more than one location for this type of information – and different options are used by different implementations resulting in highly non-standardized usage of this critical information. Proposal is that this information is captured ONLY in one way, universally across systems. |
In FHIR R4, MedicationRequest.reported[x] (https://www.hl7.org/fhir/medicationrequest-definitions.html#MedicationRequest.reported_x_) supplied either a boolean or Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) In FHIR R4 MedicationStatement - FHIR v4.0.1 (https://www.hl7.org/fhir/medicationstatement.html) which is still sometimes used to represent reported medications, a number of key terminologies are utilized |
Scott Gordon | Food and Drug Administration | |
| 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. |
HHS Disability Status - Cognitive | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
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. |
HHS Disability Status - Activities of Daily Living | According to the HHS implementation guide there are six-item set of questions used on ACS and other major surveys to gauge disability is the data standard for survey questions on disability. (HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status | ASPE). https://aspe.hhs.gov/reports/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-disability-0 The prompt for this data element should be consistent with HHS implementation guide: “Do you have difficulty dressing or bathing?” |
HL7 FHIR: US Public Health Disability Status HL7 CDA: Disability Status Observation VSAC Value Set: Disability Status (LOINC) |
Nedra Garrett | CDC | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Referral note | Documentation sent to a consultant, for example, by a primary care provider, summarizing the patient’s clinical history and reason for consult. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Work Information | Job Employer Address | The self-reported Employer Address; this is not necessarily the work location. |
LOINC (r) 80429-4 Employer address |
Nedra Garrett | CDC | ||
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Plan of care note | Documentation about expected but pending or ongoing orders, interventions, encounters, services, and procedures for a patient. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Transfer summary note | A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting. |
LOINC. We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process. |
Swapna Abhyankar | Regenstrief Institute, LOINC Document Ontology Subcommittee | |
| Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Expanded list of clinical notes, detailed in Data Element Description | Audiometry/Audiology Audiograms: (68635-2 Audiology Diagnostic study note) Psychology Reports Mental Status Evaluation: (94798-6 Psychology Diagnostic study note) Neuropsychological Testing: (94798-6 Psychology Diagnostic study note) Psychological Testing: (94798-6 Psychology Diagnostic study note) Cardiac Reports Angiogram: (75425-9 Cardiology Diagnostic study note) Cardiac Catheterization: (75425-9 Cardiology Diagnostic study note) Doppler Test (75425-9 Cardiology Diagnostic study note) Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation: (75425-9 Cardiology Diagnostic study note) EKG/ECG Tracing Image: (75425-9 Cardiology Diagnostic study note) Echocardiogram result/interpretation: (75425-9 Cardiology Diagnostic study note) Stress Testing (exercise, pharma): (83539-7 Cardiology Risk assessment & screening note) Holter monitor: (83539-7 Cardiology Risk assessment & screening note) Neurology Electroencephalogram (EEG): (68556-0 Neurology Diagnostic study note) Electromyogram/nerve conduction (EMG): (68556-0 Neurology Diagnostic study note) Myelogram: (68556-0 Neurology Diagnostic study note) Ophthalmology/Optometry Visual Acuity: (78573-3 Ophthalmology Diagnostic study note) Visual Fields: (78573-3 Ophthalmology Diagnostic study note) Radiology (Interpretations Only; No Images) CT: (68604-8 Ophthalmology Diagnostic study note) MRI: (68604-8 Ophthalmology Diagnostic study note) PET: (68604-8 Ophthalmology Diagnostic study note) X-Ray: (68604-8 Ophthalmology Diagnostic study note) Respiratory DLCO Study: (80792-5 Pulmonary Diagnostic study note) Pulmonary Function Study: (80792-5 Pulmonary Diagnostic study note) Spirometry Test result/interpretation: (80792-5 Pulmonary Diagnostic study note) Spirometry Tracing Image: (80792-5 Pulmonary Diagnostic study note) Surgical Diagnostics Bone Marrow (Biopsy/Aspiration): (48807-2 Bone marrow aspiration report) Colonoscopy: (18746-8 Colonoscopy study report) Endoscopy: (18751-8 Endoscopy study report) Additional Procedures Ultrasound (exclude Doppler): (59282-4 Stress cardiac echo study report) Genetic Testing: (51969-4 Genetics analysis report) Physical Exam: (29545-1 Physical findings narrative) |
LOINC—although we would like to see the set of codes constrained as suggested above. In Data Element Description above, we have the suggested LOINC code (showing also the Long Common Name) for each Note in our list. Such constraints are needed in order to allow for semantic interoperability. |
KarenP-SSA | Social Security Administration (SSA) |