USCDI Export for the Public

The amount of the medication given at one administration event.

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

A code (or set of codes) that specify the medication that was administered.

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

A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true).

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

An integer value used to version successive replacement documents of an electronic case report.

The area of social risk documented for a patient (e.g., housing insecurity, alcohol use, transportation security). When exchanging a domain, the following constituent data components should be included: - Source/Assessment: The specific survey, questionnaire, or question set(s) used to calculate the patient’s risk value for the domain, if applicable. If a particular assessment was not used to calculate the patient’s risk value, just the risk value may be exchanged. - Risk Value: The category of risk that applies to a patient for the domain (e.g., “high risk,” “moderate risk,” “low risk,” or “unknown”). - Date: The date the assessment was completed.

LOINC can be used to express a number of assessments used to evaluate a patient’s social determinants of health. SNOMED CT can be used to document a clinical observation stemming from an assessment when it is appropriate.

Data element capturing seasonal or migrant farm work status.

Veteran Status: Z56.82 Military deployment status Farmworker Status: ICD: Z57.2 Occupational exposure to dust Z57.3 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.6 Occupational exposure to extreme temperature Z57.8 Occupational exposure to other risk factors Agricultural/animal husbandry worker (occupation) - SNOMED: 106390009 Refugee Status: Refugee family (social concept) - SNOMED: 413323004 Refugee (person) - SNOMED: 446654005 Are you a refugee? - LOINC: 93027-1 Refugee - LOINC: LA29153-6

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

Data element capturing the refugee status of a patient

Veteran Status: Z56.82 Military deployment status Farmworker Status: ICD: Z57.2 Occupational exposure to dust Z57.3 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.6 Occupational exposure to extreme temperature Z57.8 Occupational exposure to other risk factors Agricultural/animal husbandry worker (occupation) - SNOMED: 106390009 Refugee Status: Refugee family (social concept) - SNOMED: 413323004 Refugee (person) - SNOMED: 446654005 Are you a refugee? - LOINC: 93027-1 Refugee - LOINC: LA29153-6

standard date formats

An identifier that is common across all document revisions.

Numeric or alphanumeric code that uniquely identifies a document.

Tobacco/Nicotine containing products used as a method of consumption. Question Prompt: What type(s) of tobacco products? Permissible Values: o Cigarette (SNOMED: 66562002) A thin cylinder of ground or shredded tobacco that is wrapped in paper, lit, and smoked. o Cigar (SNOMED: 26663004) A tube of tobacco that is thicker than a cigarette, wrapped in tobacco leaf, lit, and smoked. Cigars include regular cigars, cigarillos, and little filtered cigars. o Pipe (SNOMED: 84498003) A tube with a small bowl at one end that is filled with tobacco, lit, and smoked. o Smokeless (SNOMED: TBD) This delivery mechanism does not require smoking and includes, Chewing tobacco, Dip, Snuff, Dissolvable and Snus. o E-Cigarette/Vape (SNOMED: TBD) An electronic cigarette is a vaporizer device that simulates smoking by providing some of the aspects of smoking that includes nicotine but without combusting tobacco. Also called E-Cigs, Personal Vaporizer. o Unknown-(SNOMED: TBD) An individual for whose tobacco product use is unknown.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

Structured data captured in a Medication Administration Report (usually for inpatients) showing each drug administered, who administered it, what time it was administered, etc.

LOINC has codes for flowsheet elements/structured clinical data including for prenatal, cancer staging, and medication administration (clinical LOINC), FHIR R4 Observation resource, MedicationAdministration, among others, can be used to communicate the information.

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

Indicator of the progression of a study subject through a study.

CDISC standards, HL7 FHIR research-study-state, researchsubject (formerly known as Data Access Framework (DAF))

The patient’s pack-years of smoking, or the information needed to determine the pack-years (e.g., packs per day and years of smoking).

Unified Code for Untis of Measure (UCUM) units for pack years and packs per day. There is also a LOINC code for packs per day (8663-7) and years smoked (88029-4).

AMIA recommends a more thorough breakdown of the Medical Devices Data Class. For medical devices, there should be a distinguishment between permanent versus temporary data classes. Temporary devices for example PICC line, indwelling foley and suprapubic catheters, and wound vacs. Medical applications should also be included as they are considered medical digital devices, such as digital therapeutics, standard languages, payor exchanges, what is included and excluded in this category.

FDA Unique Device Identification (UDI) System

This is the collection method of the specimen sent for laboratory testing.

SNOMED CT®

Study subject is part of

CDISC standards, HL7 FHIR researchstudy, researchsubject (formerly known as Data Access Framework (DAF))

Device ID where dataset or data element was originated (collected, captured, sourced), updated, verified, attested, transformed... Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Device ID is part of “where”. Device ID must be associated with each USCDI dataset or data element that has a unique provenance set. Occurs when data is originated (captured, collected or sourced), updated, verified, attested, transformed (e.g., to/from exchange artifact such as HL7 v2 message, document or FHIR resource instance). Note that Device ID is intrinsic to what the source EHR/HIT system already knows, thus it does not require extra data collection (burden) by the clinician or other end user.