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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 | |||||||
Substance (Non-Medication) |
| Pre-existing coverage in the bound Grouped value set Common substances for allergy and intolerance documentation including refutations Within the contained sets: | Yes | Pre-existing coverage in the bound Grouped value set Common substances for allergy and intolerance documentation including refutations Within the contained sets: | Yes | Sara, Matt, Al, Gay, Brett | |
Encounter Information | |||||||
Encounter Identifier |
| NA | Yes Encounter.identifier has been required for several years | NA | Yes Encounter.id has been required for several years | Sara, Matt, Al, Gay, Brett | |
Facility Information | |||||||
Facility Identifier |
| NA | Yes
| NA | Yes
| Alex, Matt, Sara, Brett , Gay | |
Facility Type |
| NA | Yes
| NA | Yes
| Alex, Matt, Sara, Brett , Gay | |
Facility Name |
| NA | Yes
| NA | Yes
| Alex, Matt, Sara, Brett , Gay | |
Goals and Preferences | |||||||
Treatment Intervention Preference |
|
| Yes |
| Yes | Sara, Matt, Al, Gay, Brett We noted observation.value is required in C-CDA, but MS in US Core | |
Care Experience Preference |
|
| Yes |
| Yes | Sara, Matt, Al, Gay, Brett We noted observation.value is required in C-CDA, but MS in US Core | |
Health Status Assessments | |||||||
Alcohol Use |
|
| Yes |
| Yes | 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 |
|
| Yes |
| Yes | 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 |
|
| Yes |
| Yes | 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 | |||||||
Result Unit of Measure |
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay | |
Result Reference Range |
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay | |
Result Interpretation |
| Yes | US Core Laboratory Result Observation Profile | Yes | Result Observation | Alex, Matt, Sara, Brett , Gay | |
Specimen Source Site |
| Yes | US Core Specimen Profile | Yes | Yes | Alex, Matt, Sara, Brett , Gay | |
Specimen Identifier |
| Yes | US Core Specimen Profile | Yes | Yes | Alex, Matt, Sara, Brett , Gay | |
Specimen Condition Acceptability |
| Yes | US Core Specimen Profile | Yes | Yes | 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 | |||||||
Medication Instructions | Directions for administering or taking a medication. | NA | Yes | NA* | Yes | Alex, Al, Sara, Brett , Gay | |
Medication Adherence | Statement of whether a medication has been consumed according to instructions. | Yes, SNOMED CT for "answers" | Yes | Yes, SNOMED CT at observation.value for answers | Yes * | Alex, Al, Sara, Brett , Gay | |
Procedures | |||||||
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 | |||||||
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 | Yes LOINC | Yes | Sara, Matt, Al, Gay, Brett | |
Changes to USCDI Data Elements Introduced Prior to v4 | |||||||
Does change break any USCDI rules? | Change | ||||||
Patient Demographics | |||||||
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* | Alex, Al, Sara, Brett , Gay | ||||||
Smoking Status | No | US Core:
C-CDA:
| US Core Smoking Status Observation Profile | Smoking Status* | Alex, Al, Sara, Brett , Gay |