USCDI Export for the Public

Initial evaluation note, LOINC code = 28636-9, and any LOINC LongName Note which has Initial Evaluation Note as a component.

LOINC https://loinc.org/67781-5/ https://loinc.org/28636-9/ https;//loinc.org/34108-1/

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/

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

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.

Indicates who or what performed the medication administration and how they were involved.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

Patient vital status of alive/dead.

Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion

Medicare Beneficiary Identifiers (MBI) used to uniquely identify Medicare patients.

MBI format specifications: https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf HL7 Identifier type value set, see MC (http://hl7.org/fhir/R4/v2/0203/index.html)

This is the address start and end date. The time period is important in determining the current address versus address at diagnosis.

Social Security Administration: https://www.ssa.gov/history/ssn/geocard.html Medicare Beneficiary Identifiers (MBIs): https://www.cms.gov/Medicare/New-Medicare-Card PHIN VADS: Patient Marital Status: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=DB54A32E-D583-4A24-BD9C-234B0C7BD0FD Gender Identity - Gender harmony project definitions: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/lgbtfieldguidepdf.pdf?db=web&hash=224B46C31193399359B8113698971F26 FHIR patient extension: birthplace: http://hl7.org/fhir/R4/extension-patient-birthplace.html FHIR patient address.period: http://hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html LOINC pregnancy status: https://loinc.org/82810-3/ Patient Vital Status: PHIN VADS, SNOMED-CT: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=6EA795D5-5C5D-E511-81F8-0017A477041A Patient vital status:CCDA uses Value Set - HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 Value Set Source: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.12/expansion

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

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

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.

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

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

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.

Unique, disambiguating identifier components for Organization-related elements. e.g. Provenance, identifier.assigner, and other elements and components that rely upon Organizations, especially those that may not be provider organizations nor have a URL. USCDI may need to support (or even consider requiring) organization.identifier.system to improve data portability. The parent way of identifying the system that enumerates multiple Organization identifiers may best be modeled as Organization.identifier.system, where the identifier uses existing FHIR properties for Identifiers data type. These include: identifier.system (URI namepsace) identifier.assigner (itself an organization!) identifier.value (a unique value)

For organizations like payers and ACOs, while health plan ID is no longer being pursued by industry, existing, in-production Payer IDs exist in multiple EDI (Electronic Data Interchange) environments. There are a set of Payer IDs in use today already; in concert with a clear description of the system that enumerates the Payer ID, these can be an example of the standards that may be used in uniquely identifying organizations beyond a free-text string description/label. These IDs may, however, be proprietary, but also already permissioned for use by the trading partners of the entities using the IDs for treatment, payment, and health care operations.