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Final Design awareness - US Core |
Final Design awareness - C-CDA | Attendees |
| Category | Fields | USCDI Definition and vocab | USCDI Recommended Terminology Present? (Do Terminology bindings agree with what is declared in USCDI) | Design covers USCDI Definition?
| USCDI Terminology Present? (Do Terminology bindings agree with what is declared in USCDI) | Design covers USCDI Definition?
| Team members present when awareness sign-off occurred |
| Allergies and Intolerances |
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| Substance (Non-Medication) | - Non-pharmacologic agent believed to cause a harmful or undesired physiologic response following exposure.
- SNOMED CT
| | Yes US Core AllergyIntolerance Profile | | Yes Allergy - Intolerance Observation | Sara, Matt, Al, Gay, Brett |
| Encounter Information |
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| Encounter Identifier | - Sequence of characters by which an encounter is known.
- NA
| NA | Yes US Core Encounter Profile Encounter.identifier has been required for several years | NA | Yes Encounter Activity Encounter.id has been required for several years | Sara, Matt, Al, Gay, Brett |
| Facility Information |
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| Facility Identifier | - Sequence of characters representing a physical place of available services or resources.
- NA
| NA | Yes US Core Location Profile | NA | Yes Service Delivery Location | Alex, Matt, Sara, Brett , Gay |
| Facility Type | - Category of service or resource available in a location.
- NA
| NA | Yes US Core Location Profile | NA | Yes Service Delivery Location | Alex, Matt, Sara, Brett , Gay |
| Facility Name | - Word or words by which a facility is known.
- NA
| NA | Yes US Core Location Profile | NA | Yes Service Delivery Location - ParticipantRole.PlayingEntity.name
| Alex, Matt, Sara, Brett , Gay |
| Goals and Preferences |
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| Treatment Intervention Preference | - Person's goals, preferences, and priorities for care and treatment in case that person is unable to make medical decisions because of a serious illness or injury.
- LOINC
| - Yes, LOINC represents the "Question" code (@observation.code).
- "Answers" (@observation.value) are most often text, but systems must also be able to capture encoded values
| Yes US Core Treatment Intervention Preference Profile | - Yes, LOINC represents the "Question" code (@observation.code).
- "Answers" (@observation.value) are most often text. This is described in the template as well as the usual guidance about text referencing
| Yes Treatment Intervention Preference | Sara, Matt, Al, Gay, Brett We noted observation.value is required in C-CDA, but MS in US Core |
| Care Experience Preference | - Person's goals, preferences, and priorities for overall experiences during their care and treatment.
- LOINC
| - Yes, LOINC represents the "Question" code (@observation.code).
- "Answers" (@observation.value) are most often text, but systems must also be able to capture encoded values
| Yes US Core Care Experience Preference Profile | - Yes, LOINC represents the "Question" code (@observation.code).
- "Answers" (@observation.value) are most often text. This is described in the template as well as the usual guidance about text referencing
| Yes Care Experience Preference
| Sara, Matt, Al, Gay, Brett We noted observation.value is required in C-CDA, but MS in US Core |
| Health Status Assessments |
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| Alcohol Use | - Evaluation of a patient's consumption of alcohol.
- LOINC
| - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Assesments Guidance | - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Asssessment Guidance | Alex, Matt, Sara, Brett , Gay Team noted to create in C-CDA Guidance page a similar table to this in US Core https://build.fhir.org/ig/HL7/US-Core/screening-and-assessments.html#structured-screening-and-assessments |
| Substance Use | - Evaluation of a patient's reported use of drugs or other substances for non-medical purposes or in excess of a valid prescription.
- LOINC
| - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Assesments Guidance | - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Asssessment Guidance | Alex, Matt, Sara, Brett , Gay Team noted to create in C-CDA Guidance page a similar table to this in US Core https://build.fhir.org/ig/HL7/US-Core/screening-and-assessments.html#structured-screening-and-assessments |
| Physical Activity | - Evaluation of a patient's current or usual exercise.
- LOINC
| - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Assesments Guidance | - Yes LOINC Panel and/or LOINC Panel item codes
| Yes Screening and Asssessment Guidance | Alex, Matt, Sara, Brett , Gay Team noted to create in C-CDA Guidance page a similar table to this in US Core https://build.fhir.org/ig/HL7/US-Core/screening-and-assessments.html#structured-screening-and-assessments |
| Laboratory |
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| Result Unit of Measure | - Unit of measurement to report quantitative laboratory test results.
- UCUM
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay |
| Result Reference Range | - Upper and lower limit of quantitative test values expected for a designated population of individuals.
- UCUM
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay |
| Result Interpretation | - Categorical assessment of a laboratory value, often in relation to a test's reference range.
- SNOMED CT
- HL7 Code System ObservationInterpretation
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay |
| Specimen Source Site | - Body location from where a specimen was obtained.
- SNOMED CT
| Yes | US Core Specimen Profile | Yes | Yes Specimen Collection Procedure | Alex, Matt, Sara, Brett , Gay |
| Specimen Identifier | - Sequence of characters assigned by a laboratory for an individual specimen.
- NA
| Yes | US Core Specimen Profile | Yes | Yes Result Organizer | Alex, Matt, Sara, Brett , Gay |
| Specimen Condition Acceptability | - Information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability.
- SNOMED CT
- Health Level 7® (HL7) Code System SpecimenCondition
| Yes | US Core Specimen Profile | Yes | Yes Specimen Condition Observation | Alex, Matt, Sara, Brett , Gay Discussion about SNOMED vs the V2 sets. Value set update project - We will investigate to see if we can update the used V2 set (https://terminology.hl7.org/5.3.0/ValueSet-v2-0493.html) with additional terms from Specimen Reject Reason (https://terminology.hl7.org/5.3.0/ValueSet-v2-0490.html) |
| Medications |
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| Medication Instructions | Directions for administering or taking a medication. | NA | Yes US Core Medication Request | NA | Yes Medication Free Text Sig
| Alex, Al, Sara, Brett , Gay |
| Medication Adherence | Statement of whether a medication has been consumed according to instructions. | Yes, SNOMED CT for "answers" | Yes US Core Medication Request | Yes, SNOMED CT at observation.value for answers | Yes Medication Adherence | Alex, Al, Sara, Brett , Gay |
| Procedures |
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| Performance Time | Time and/or date a procedure is performed. | NA | US Core Procedure Profile
US Core DiagnosticReport Profile for Report and Note Exchange
US Core Immunization Profile | NA | Yes Procedure Activity Procedure (effectiveTime) | Alex, Al, Sara, Brett , Gay |
| Vital Signs |
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| Average Blood Pressure | Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol.Information Source for Medication Adherence | Yes, LOINC | Yes US Core average Blood Pressure | Yes LOINC | Yes Average Blood Pressure | Sara, Matt, Al, Gay, Brett Notes: C-CDA: 1) Contained Observations should not be VS Observations 2) should give guidance as to where the method could be sent if recorded |
| Changes to USCDI Data Elements Introduced Prior to v4 |
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| Does change break any USCDI rules? | Change |
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| Patient Demographics |
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| Gender Identity | No | Concept to cover conceptual definition of "X" added to value set. 33791000087105 | Identifies as nonbinary gender (finding) | which has a synonym that aligns with state a federal definitions of "X": "Fluctuating between male and female, or identifying as either having a gender that is in-between or beyond the two categories or as having no gender, either permanently or some of the time." | Gender Identity Extension | Gender Identity Observation Template |
| Sara, Matt, Al, Gay, Brett |
| Sex | No | Codes Added: SCT: Identifies as nonbinary gender (finding) DAR: Asked But Declined | US Core Sex Extension | Sex Observation |
| Alex, Al, Sara, Brett , Gay |
| Sexual Orientation | No | Codes Added: OTH other UNK unknown asked-declined Asked But Declined | US Core Observation Sexual Orientation Profile | Sexual Orientation Observation |
| Alex, Al, Sara, Brett , Gay |
| Health Status Assessments |
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| Alex, Al, Sara, Brett , Gay |
| Smoking Status | No | US Core: - Value set created at observation.code to allow encoded answer or an integer answer for answers to "Pack Years"
- Requested LOINC code for ""Electronic Cigarette Use Status" to be added to the observation.code value set (Submission ID: 7156)
- Expanded (SNOMED CT) value set at Observation.value to include vaping codes and some situation codes missing
C-CDA: - Deprecated "Smoking Status Meaningful Use" Template
- Deprecated "Tobacco Use" Template
- Created new Smoking Status template that aligns with the new version of US Core Smoking Status
- USCDI Table points to the new Smoking Status Template
| US Core Smoking Status Observation Profile | Smoking Status |
| Alex, Al, Sara, Brett , Gay |
