Understanding USCDI Data Classes
The United States Core Data for Interoperability (USCDI) is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.
From a developer perspective, it's important to understand the data classes because an ONC certified electronic health record is required to expose well formed data via API in order to be compliant.
The USCDI guides are generally very helpful, as they provide guidance on how to represent common things like "Smoking Status", "Consultation Note" - they have a helpful overview available online. The US Core Profiles is also very useful.
At a high level, if you have:
- Data modeled as FHIR
- Tagged with the right code systems
- Populated with required fields
An implementation will be compliant and interoperability ready.
Medplum supports: US Core 5.0.1 / USCDI v2
Summary Table
We find the following table useful to summarize common data elements found in an EHR to help implementors get started quickly.
| USCDI Data Classes/Elements | US Core Profiles | FHIR Resources |
|---|---|---|
| Allergies and Intolerances: ● Substance (Medication) ● Substance (Drug Class) ● Reaction | US Core AllergyIntolerance Profile | AllergyIntolerance |
| Assessment and Plan of Treatment | US Core CarePlan Profile | CarePlan |
| Care Team Members | US Core CareTeam Profile | CareTeam |
| Clinical Notes: ● Consultation Note ● Discharge ● Summary Note ● History & Physical ● Progress Note ● Consultation Note | US Core DocumentReference Profile US Core Condition DiagnosticReport Profile for Report and Note Exchange | DocumentReference |
| Clinical Tests: ● Clinical Test ● Clinical Test Result/Report | US Core Clinical Test Result Observation Profile US Core Condition DiagnosticReport Profile for Report and Note Exchange | DocumentReference |
| Diagnostic Imaging: ● Diagnostic Imaging Test ● Diagnostic Imaging Report | US Core Diagnostic Imaging Result Observation Profile US Core Condition DiagnosticReport Profile for Report and Note Exchange | DocumentReference |
| Encounter Information ● Encounter Type ● Encounter Diagnosis ● Encounter Time ● Encounter Location ● Encounter Disposition | US Core Encounter Profile US Core Condition Encounter Diagnosis Profile | Encounter Condition |
| Goals: Patient Goals | US Core Goal Profile | Goal |
| Goals: Health Concerns | US Core Conditions, Problems and Health Concerns Profile | Condition |
| Immunizations | US Core Immunization Profile | Immunization |
| Laboratory ● Tests ● Values/Results | US Core Laboratory Result Observation Profile US Core DiagnosticReport Profile for Report and Note Exchange | Observation DiagnosticReport |
| Medications | US Core Medication Profile US Core Medication Request Profile | Medication MedicationRequest |
| Patient Demographics: ● First Name ● Last Name ● Previous Name ● Middle Name/Initial ● Suffix ● Birth Sex ● Date of Birth ● Race ● Ethnicity ● Preferred Language ● Address ● Phone Number | US Core Patient Profile | Patient resource docs Patient.name.given Patient.name.family Patient.name Patient.name.given Patient name.suffix US Core Birth Sex Ext. Patient.birthDate US Core Race Extension US Core Ethnicity Extension Patient.communication Patient.address Patient.telecom |
| Problems | US Core Condition Problems and Health Concerns Profile | Condition |
| Procedures | US Core Procedure Profile | Procedure |
| Provenance: ● Author Time Stamp ● Author Organization | US Core Provenance Profile | Provenance resource docs Provenance.recorded Provenance.agent |
| Smoking Status | US Core Smoking Status Observation | Observation |
| Implantable Device | US Core Implantable Device Profile | Device |
| Vitals: ● Diastolic blood pressure ● Systolic blood pressure ● Body height ● Body weight ● Heart rate ● Respiratory rate ● Body temperature ● Pulse oximetry ● Inhaled oxygen concentration ● BMI Percentile (ages 2-20) ● Weight-for-length (0-36mos) ● Occipital-frontal Head Circumference (0-36mos) | B/P systolic and diastolic Body Height Body Weight Heart Rate Respiratory Rate Body Temperature US Core Pulse Oximetry Profile US Core Pediatric BMI for Age US Core Pediatric Weight for Height US Core Pediatric Head Circumference | Observation |
Sample Data
The Inferno team provides representative sample data that conforms to the USCDI specification. Download and import instructions sample data into your Medplum project.