USCDI Export for the Public

Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79893-4

LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4

Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC LOINC- 79892-6

LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4

Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg). Source: Regenstrief LOINC

LOINC part LP96294-1 Right eye 79892-6 Left eye 79893-4

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

Purpose of Capture describes why a dataset or data elements were originated (collected, captured, sourced), updated, verified, attested, transformed... Often needed to ensure Purpose of Capture is equivalent or compatible with each potential Purpose of Use. Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Purpose of Capture is part of “why”. Purpose of Capture should 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 Purpose of Capture may be intrinsic to what the source EHR/HIT system already knows, thus it will not require extra data collection (burden) by the clinician or other end user.

(Per https://www.hl7.org/fhir/provenance.html): “Provenance.signature: A digital signature on the target Reference(s). The digital signature, inclusive of a hash on the resource being signed (Provenance.signature.type = 1.2.840.10065.1.12.1.14), will ensure that the integrity of the particular electronic health information (EHI) is maintained and not altered in any way. This allows recipients of this EHI to trust the integrity of the content regardless of its most recent origin. • As patient-mediated EHI becomes more prevalent, maintaining the chain of trust via this digital signature will be instrumental in patient-provided health information exchange.

HL7 FHIR R4 (v4.01: R4 – Mixed Normative and STU)

Medical: Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit.
Pharmacy: Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

ICD-9-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. (UB04 Form Locator 69). Decimals will be included.
Facility: The member's principal condition treated during this service. (UB04 Form Locator 67). This may or may not be different from the admitting diagnosis. Decimals will be included.
Professional and Non-Physician: The member's principal condition treated during this service.
Additional diagnosis identified for this member. Decimals will be included.
ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included.
The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included.
Additional diagnosis identified for this member. Decimals will be included.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

This is any valid ICD-10 Diagnosis code in the range V00.* through Y99.*

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Author Credential(s), in context of action taken and/or in context of USCDI dataset or data element authorship. Should allow credentials such as MD, DO, RN, DDS, PharmD...

Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Author Credential(s) are part of “who”.

Author Credential(s) 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.

Note that Author Credential(s) are 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.

Action Taken, in context of the real-world occurrence (activity or event) that included collection of the USCDI dataset or data element. Actions include: assessment, history and physical, admission, discharge, transfer, order (e.g., for diagnostic test, for care, for therapy, for medications), result or interpretation (e.g., of diagnostic test), referral, consultation, care planning, observation... Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Action Taken is part of “what”. Action Taken 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 Action Taken 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.

Data State, in context of data lifecycle. States should include: origination (capture, collection), update (from previous content/value), verification (of data sourced by others (e.g., transcriptionist, scribe, student) or from automated device), transformation (e.g., from source system internal representation to exchange artifact (such as HL7 message, CDA document or FHIR resource), from exchange artifact to receiver internal representation). Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Data State is part of “what”. Data State 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 Data State 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.

Location where action was taken and/or where dataset or data element was collected (captured, sourced). Location should include room (within) building (within) organization. Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Physical Location is part of “where”. Physical Location 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 Physical Location 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.

Network Address 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. Network Address is part of “where”. Network Address 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 Network Address 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.

Rationale describes why an action was taken (i.e., the action during which the dataset and/or data element was originated (collected, captured, sourced)). Provenance set includes the who, what, when, where and why as metadata for USCDI data classes and data elements. Rationale is part of “why”. Rationale should be associated with each USCDI dataset or data element that has a unique provenance set. Occurs when action-related 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 Rationale may be intrinsic to what the source EHR/HIT system already knows, thus it will not require extra data collection (burden) by the clinician or other end user.

The globally unique identifier for each blood or biologic product identified using the ISBT 128 international standard.

ISBT 128

ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included.
The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included.
Additional diagnosis identified for this member. Decimals will be included.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included.
The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included.
Additional diagnosis identified for this member. Decimals will be included.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

Indicates if the diagnosis is admitting, principal, other, an external cause of injury or secondary

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.