Difference between revisions of "USCDI"
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'''References''' | '''References''' | ||
− | 1. United States Core Data for Interoperability (USCDI) | Interoperability Standards Advisory (ISA) (healthit.gov) | + | 1. United States Core Data for Interoperability (USCDI) | Interoperability Standards Advisory (ISA) (healthit.gov) [https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi] |
− | 2. Cures Act Final Rule - United States Core for Interoperability (healthit.gov) | + | 2. Cures Act Final Rule - United States Core for Interoperability (healthit.gov) [https://www.healthit.gov/sites/default/files/page2/2020-03/USCDI.pdf] |
− | + | ||
− | + | ||
+ | 3. Federal Register :: 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program [https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification] | ||
4. United States Core Data for Interoperability (USCDI) - Version 4 - October 2023 Errata (healthit.gov) | 4. United States Core Data for Interoperability (USCDI) - Version 4 - October 2023 Errata (healthit.gov) | ||
− | + | [https://www.healthit.gov/isa/sites/isa/files/2023-10/USCDI-Version-4-October-2023-Errata-Final.pdf] | |
Submitted by Michael Albrecht | Submitted by Michael Albrecht | ||
[[Category:BMI512-SPRING-24]] | [[Category:BMI512-SPRING-24]] |
Revision as of 13:40, 30 April 2024
United States Core Data for Interoperability (USCDI) is a standardized set of health data classes and constituent data elements that facilitates interoperable health information exchange across the United States.
History
The 21st Century Cures Act was passed in 2016. Title IV of this Act vested the Office of the National Coordinator of HIT (ONC) with creating a Final Rule (finalized in March 2020), whose provisions were "designed to advance interoperability; support the access, exchange, and use of electronic health information (EHI); and address occurrences of information blocking."[3] As part of this Final Rule, the first version of the USCDI was adopted as a data exchange standard.[3] The goal of creating the USCDI was to "[specify] a common set of data classes and elements that have been designed to improve data usage and interoperable data exchange."[3] The USCDI expanded upon the Common Clinical Data Set (CCDS) that had been established as part of the a prior Final Rule. [3]
What USCDI is and is not [3]
-The USCDI is not specific to a setting of care, a healthcare specialty, or a specific category of health IT user
-The USCDI is not specific to a particular content exchange standard (e.g., HL7 C-CDA, HL7 FHIR, HL7 V2, or NCPDP SCRIPT).
-The USCDI does apply to the certification of health IT and certified health IT's ability to send and receive the Data Elements defined by USCDI.
Data Element and Data Classes
Comprising a standardized set of health Data Classes and constituent Data Elements, USCDI structures information around common themes or use cases. [3]
USCDI Data Class - an aggregation of Data Elements by a common theme or use case [1]
USCDI Data Element - a piece of data defined in USCDI for access, exchange or use of electronic health information [1]. Some of the data elements used required healthcare standards (e.g., LOINC, SNOMED CT, IIS, NDC) while others do not [4].
A complete list of data classes, data elements, and applicable vocabulary standards can be found on the USCDI website [1] and on the associated standard document for each USCDI version. [4]
Versions
Version - Publication Date
USCDI v1 - February 2020
USCDI v2- July 2021
USCDI v3 - July 2022
USCDI v4 - July 2023
USCDI v5 - (Draft status)
USCDI v4 Summary of Data Classes and Data Elements
Allergies and Intolerances
Substance (Medication)
Substance (Drug Class)
Substance (Non-Medication)
Reaction
Care Team Members(s)
Care Team Member Name
Care Team Member Identifier
Care Team Member Role
Care Team Member Location
Care Team Member Telecom
Clinical Notes
Consultation Note
Discharge Summary Note
History & Physical
Procedure Note
Progress Note
Clinical Tests
Clinical Test
Clinical Test Result/Report
Diagnostic Imaging
Diagnostic Imaging Test
Diagnostic Imaging Report
Encounter Information
Encounter Type
Encounter Identifier
Encounter Diagnosis
Encounter Time
Encounter Location
Encounter Disposition
Facility Information
Facility Identifier
Facility Type
Facility Name
Goals and Preferences
Patient Goals
SDOH Goals
Treatment Intervention Preference
Care Experience Preference
Health Insurance Information
Coverage Status
Coverage Type
Relationship to Subscriber
Member Identifier
Subscriber Identifier
Group Identifier
Payer Identifier
Health Status Assessments
Health Concerns
Functional Status
Disability Status
Mental/Cognitive Status
Pregnancy Status
Alcohol Use
Substance Use
Physical Activity
SDOH Assessment
Smoking Status
Immunizations
Immunizations
Laboratory
Tests
Values/Results
Specimen Type
Result Status
Result Unit of Measure
Result Reference Range
Result Interpretation
Specimen Source Site
Specimen Identifier
Specimen Condition Acceptability
Medical Devices
Unique Device Identifier - Implantable
Medications
Medications
Dose
Dose Unit of Measure
Indication
Fill Status
Medication Instructions
Medication Adherence
Patient Demographics/Information
First Name
Last Name
Middle Name (including middle initial)
Name Suffix
Previous Name
Date of Birth
Race
Ethnicity
Tribal Affiliation
Sex
Sexual Orientation
Gender Identity
Preferred Language
Current Address
Previous Address
Phone Number
Phone Number Type
Email Address
Related Person's Name
Relationship Type
Occupation
Occupation Industry
Patient Summary and Plan
Assessment and Plan of Treatment
Problems
Problems
SDOH Problems/Health Concerns
Date of Diagnosis
Date of Resolution
Procedures
Procedures
Performance Time
SDOH Interventions
Reason for Referral
Provenance
Author Time Stamp
Author Organization
Vital Signs
Systolic Blood Pressure
Diastolic Blood Pressure
Average Blood Pressure
Heart Rate
Respiratory Rate
Body Temperature
Body Height
Body Weight
Pulse Oximetry
Inhaled Oxygen Concentration
BMI Percentile (2-20 years)
Weight-for-length Percentile (Birth-24 months)
Head Occipital-frontal Circumference Percentile (Birth-36 months)
References
1. United States Core Data for Interoperability (USCDI) | Interoperability Standards Advisory (ISA) (healthit.gov) [1]
2. Cures Act Final Rule - United States Core for Interoperability (healthit.gov) [2]
3. Federal Register :: 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program [3]
4. United States Core Data for Interoperability (USCDI) - Version 4 - October 2023 Errata (healthit.gov) [4]
Submitted by Michael Albrecht