Difference between revisions of "USCDI"

Revision as of 13:27, 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. [1] The first version (USCDI v1) was adopted as a standard in the ONC Cures Act Final Rule. [2]

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 use 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, MD