APPENDIX 1.
Table 1: Draft review of Common Core Data Elements for Case Reporting and Laboratory Result
Reporting along with data elements captured from two other meaningful use public health performance
measures for Syndromic Surveillance, Immunization, and a recent IHE profile for Cancer Reporting.
Categor
y
Report
Report
Data
element
*=
comple
x data
element
Report
date/tim
e
Alert
creation
date/tim
e^
Definition
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Report
Date/Time
- Date and
time of
report
transmissi
on from
original
source.
- If data
flows
through
an
intermedia
ry or third
party, the
intermedia
ry must
keep the
original
date/time
of
transmissi
on.
Date and
time the
report is
being
sent to
public
health
For
automa
ted
system
s,
date/ti
me a
detecti
on
algorith
m
created
the
alert
relevan
t to the
conditi
on
being
reporte
d
Immunizati
on Notes
Cancer
Reporting
Notes
Check:
ClinicalDocumen
t/effectiveTime
Check:
ClinicalDocumen
t/effectiveTime
Categor
y
Report
Data
element
*=
comple
x data
element
Reporti
ng
system^
Definition
Case
Reporti
ng
Notes
§
Reporte
r
Identifie
r*
Person
or facility
sending
the
report to
public
health
Reporte
r
Name*
Reporte
r
Facility
name
Reporte
r
Address
*
Name of
the
person or
facility
sending
the
report to
public
health
Name of
the
facility
sending
the
report to
public
health
Address
of the
person or
facility
sending
the
report to
public
health
Identifi
er
typicall
y
Nation
al
Provid
er
Identifi
er
(NPI),
may be
other
Laboratory
Result
Reporting
Notes
The sending
application/s
ending
facility is
required in
ELR IG
Typically
CLIA, may
be other,
e.g., license
number, OID
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
? N/A unless
CDA document
is wrapped
inside an HL7
2.x message (in
OBX5)
Author
(includes NPI?)
Need
clarification on
Reporter items.
Are they
relevant to
cancer?
Author?
When
the
reporte
r is an
person
Represented
Organization?
Need
clarification on
Reporter items.
Are they
relevant to
cancer?
Categor
y
Reporte
r
Reporte
r
Data
element
*=
comple
x data
element
Phone*
Email
address
%
Provide
r
[person]
Identifie
r*
Provide
r
[person]
Name*
Definition
Phone
number
of the
person or
facility
sending
the
report to
public
health
Email
address
of the
person or
facility
sending
the
report to
public
health
Identifier
of the
person
who
provided
care for
the
subject
of the
report
Name of
the
person
who
provided
care for
the
subject
of the
report
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Need
clarification on
Reporter items.
Are they
relevant to
cancer?
Need
clarification on
Reporter items.
Are they
relevant to
cancer?
Typical
ly, the
person
who
identifi
ed the
reporta
ble
conditi
on
Typically, the
person who
ordered the
laboratory
test
Check…
Physician
(Assigned
Person/Name)
Categor
y
Provide
r
[person]
Data
element
*=
comple
x data
element
Address
*
Provide
r
[person]
Phone*
Provide
r
[person]
Email
address
Provide
r
[person]
Role
%
Definition
Address
of the
person
who
provided
care for
the
subject
of the
report
Phone
number
of the
person
who
provided
care for
the
subject
of the
report
Email
address
of the
person
who
diagnose
d the
subject
of the
report
Role
played
by the
person
who
provided
care for
the
subject
of the
report
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Check: in
service event
example
Check: in
service event
example
No
Role
played
by
provide
r, e.g.,
attendi
ng
provide
r,
primary
care
provide
r
Typically,
ordering
provider
?Function code,
but not clear
which roles are
in value set
Categor
y
Orderin
g facility
Data
element
*=
comple
x data
element
Identifie
r*
Definition
Identifier
of the
facility
where
care was
provided
to the
subject
of the
report.
Orderin
g
Facility
Name*
Name of
the
facility
where
care was
provided
to the
subject
of the
report.
Orderin
g
Facility
Address
*
Address
of the
facility
where
care was
provided
to the
subject
of the
report.
Orderin
g
Facility
Phone*
Phone
number
of the
facility
where
care was
provided
to the
subject
of the
report.
Case
Reporti
ng
Notes
May be
facility
of
provide
r or
facility
where
subject
was
diagno
sed
May be
facility
of
provide
r or
facility
where
subject
was
diagno
sed
May be
facility
of
provide
r or
facility
where
subject
was
diagno
sed
May be
facility
of
provide
r or
facility
where
subject
was
diagno
sed
Laboratory
Result
Reporting
Notes
Typically,
ordering
facility
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Facility
Identifier
Unique
facility
identifier
of facility
providing
data
Probably same
as provider
identified above
Facility Name
Name of
facility
providing
data
Probably same
as provider
identified above
Facility
Location
Includes
street
address,
city,
county
and state.
Probably same
as provider
identified above
Probably same
as provider
identified above
Categor
y
Orderin
g
Facility
Subject
Data
element
*=
comple
x data
element
Email
address
%
Identifie
r*
Definition
Email
address
of the
facility
where
care was
provided
to the
subject
of the
report.
Identifier
of the
subject
of the
report
Case
Reporti
ng
Notes
May be
facility
of
provide
r or
facility
where
subject
was
diagno
sed
Typical
ly, the
subject
of the
report
is a
patient
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Probably same
as provider
identified above
Typically, the
subject of
the report is
a patient
Unique Patient
Identifier
Medical
Record #
Patient
Medical
Record
Number
It is
recommen
ded to
submit the
patient
medical
record
number to
facilitate
identificati
on of the
patient, in
the event
of a
required
follow-up
investigati
on.
Without
the
medical
record
number,
the work
required
to followup on the
health
data
provider
end
greatly
increases.
Client ID
Medical Record
Number
Social Security
Number
Categor
y
Subject
Data
element
*=
comple
x data
element
Name*
Subject
Address
*
Subject
Phone*
Subject
Email
address
%
Subject
Date of
birth
Definition
Name of
the
subject
of the
report
Address
of the
subject
of the
report
Phone
number
of the
subject
of the
report
Email
address
of the
subject
of the
report
Date of
birth
(DOB) of
the
subject
of the
report
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
State, Country
and Zip Code
(minimum of 5
digits) of
patient’s home
address
Immunizati
on Notes
Cancer
Reporting
Notes
Client ID
Patient Name
Client
Locators
Ad
dre
ss
Patient Address
History
(includes
“useable
period”)
Client
Locators
Ph
on
e
Contact?
Client
Locators
Em
ail
Contact?
Client
Demograp
hics
Birt
h
dat
e
Birthtime
Categor
y
Subject
Data
element
*=
comple
x data
element
Age
Definition
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Age of
the
subject
of the
report at
the time
of
diagnosis
Age at
time
reporta
ble
conditi
on was
identifi
ed
Age at time
of specimen
collection
Syndromic
Surveillance
Notes
Age
Numeric
value of
patient
age
The
Workgrou
p
recognize
sa
technical
constraint
where age
being
required
through
the OBX
segment
is a
deviation
from the
standard
HL7
format of
the
recommen
ded
messages
.
The
workgroup
will
explore
what the
implication
s are to
practices
due to this
requireme
nt. Note:
Sending
DOB is
not
acceptabl
e.
Immunizati
on Notes
Cancer
Reporting
Notes
No. Calculated
by registry?
Categor
y
Subject
Data
element
*=
comple
x data
element
Age
units
[code]*
Definition
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Age Units
Unit
correspon
ding to
numeric
value of
patient
age (e.g.
Days,
Month or
Years)
PHIN
VADS
Value Set
for Age
Cancer
Reporting
Notes
No.
Units
(UCUM)
Subject
Gender
Current
gender of
the
subject
of the
report
Gender
Gender of
patient
PHIN
VADS
value set
for
Client
Demograp
hics
Ge
nd
er
Administrative
Gender
Client
Demograp
hics
Ra
ce
Race
Administ
rative
Sex (HL7
v2.x)
Subject
Race
Race(s)
of the
subject
of the
report
Race
Uses
Race
Category
(not
detailed
race)
value set
PHIN
VADS
value set
for Race
Category
(CDC
REC)
Categor
y
Subject
Data
element
*=
comple
x data
element
Ethnicit
y
Definition
Ethnicity
of the
subject
of the
report
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Ethnicity
Uses
Ethnicity
Group
(hispanic
or not)
value set
PHIN
VADS
Value set
for
Client
Demograp
hics
Eth
nici
ty
Cancer
Reporting
Notes
Ethnicity
Ethnicity
Group
(CDC
REC)
Subject
Subject
Translat
or
needed
Langua
ge
spoken
Employ
ment
Occupa
tion,
current
[code]*
Employ
ment
Occupa
tion,
usual
[code]*
Employ
ment
Industry
type,
current
[code]*
No
Subject’s
primary
or
spoken
language
.
At the
time of
the
report,
the
subject’s
occupati
on(s)
Report
subject’s
longest
held
occupati
on
At the
time of
the
report,
the
industry
type(s) of
the
subject’s
occupati
on(s)
Client
Primary
Language
No
No
Usual
Occupation
No
Categor
y
Employ
ment
Data
element
*=
comple
x data
element
Industry
type,
usual
[code]*
Employ
ment
Employ
er name
Employ
ment
Employ
er,
address
*
Employ
ment
Employ
er,
phone*
Definition
Industry
type of
the
report
subject’s
longest
held
occupati
on
At the
time of
the
report,
the name
of the
subject’s
current
employer
(s)
At the
time of
the
report,
the
address
of the of
the
subject’s
current
employer
(s)
At the
time of
the
report,
the
phone
number
of the
subject’s
current
employer
(s)
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Usual Industry
No
No
No
Categor
y
Authoriz
ed
Contact
for
Subject
Data
element
*=
comple
x data
element
Name*
Authoriz
ed
Contact
for
Subject
Address
*
Authoriz
ed
Contact
for
Subject
Phone*
Authoriz
ed
Contact
for
Subject
Relation
ship
[code]*
Definition
Name of
the
authorize
d
contact(s
) for the
subject
of the
report
Address
of the
authorize
d
contact(s
) for the
subject
of the
report
Phone
number
of the
authorize
d
contact(s
) for the
subject
of the
report
Relations
hip of the
authorize
d
contact(s
) to the
subject
of the
report
Case
Reporti
ng
Notes
For
exampl
e,
parent(
s) or
guardia
n(s)
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Next of Kin
Name
Check header
definitions to
see which
element
Next of Kin
Address
Check header
definitions to
see which
element
Next of Kin
Phone
Check header
definitions to
see which
element
Next of Kin
Check header
definitions to
see which
element
Categor
y
Clinical
Informat
ion
Data
element
*=
comple
x data
element
Conditio
n
[code]*
Definition
Name of
the
condition
diagnose
d for the
subject
of the
report
Clinical
Informat
ion
Conditio
n,
date/tim
e of
onset
Date and
time the
condition
began
Clinical
Informat
ion
Conditio
n,
date/tim
e of
diagnos
is
Specim
en
collectio
n
date/tim
e
Date and
time the
condition
was
diagnose
d
Test/res
ult
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Report
able
conditi
on
prompti
ng the
submis
sion of
this
report
Laboratories
do not
diagnose,
however,
relevant
information
may be
available to
the lab as
the reason
for the study.
Syndromic
Surveillance
Notes
Diagnosis /
Injury Code
Diagnosis
or injury
code of
patient
condition.
Uses
Immunizati
on Notes
Cancer
Reporting
Notes
Check: Primary
Site, Histology,
Laterality,
Behavior?
ICD-9
Dx
codes or
SNOME
D
Disorder
Domain.
Do not
wait to
send data
until
diagnosis
is given.
This will
likely be
an update.
Date of Onset
Date that
patient
began
having
symptoms
of
condition
being
reported.
No? Verify
Diagnosis Date
? In Coded
Results Simple
Observation?
Categor
y
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Data
element
*=
comple
x data
element
Identifie
r(s)*
linking
to
laborato
ry
report
Specim
en
receive
d
date/tim
e
Specim
en type
[code]*
Specim
en
source
site
[code]*
Specim
en
origin
[code]*
Test
ordered
[code]*
Test
perform
ed
[code]*
Definition
Unique
identifier(
s) that
provide
links to a
laborator
y report
(e.g.,
accessio
n
number,
order
number,
specime
n
identifier,
study
identifier)
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
?
?
No?
No?
Domain
from
which the
specime
n comes,
e.g.,
human,
animal,
environm
ental
No?
No?
No?
Categor
y
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Data
element
*=
comple
x data
element
Test
result
[code]*
Definition
Case
Reporti
ng
Notes
A
result
may be
coded,
or it
may
not be
coded.
Exampl
es of a
noncoded
result
include
:a
numbe
r, a
ratio, a
text
report
from a
radiolo
gic
study,
an
image.
If
coded,
the
result
is
structur
ed as a
coded
comple
x data
elemen
t.
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
Coded results
Section:
primary site,
histology,
laterality and
behavior?
Result
date
Result
status
Referen
ce
range
Units
No?
Abnorm
al flag
N/A?
Not sure what
this is
N/A?
N/A
Categor
y
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Test/res
ult
Data
element
*=
comple
x data
element
Comme
nt
Perform
ing lab
identifie
r*
Perform
ing lab
name
Perform
ing
person
name*
Specim
en sent
to PHL
Definition
Case
Reporti
ng
Notes
Laboratory
Result
Reporting
Notes
Syndromic
Surveillance
Notes
Immunizati
on Notes
Cancer
Reporting
Notes
No
No?
Diagnosing
Laboratory
Name
No?
Indicator
of
whether
a
specime
n
relevant
to this
condition
was
submitte
d to a
public
health
laborator
y.
No
*Indicates a complex data element. See Table 1: Example Complex Data Elements for Case Reporting
and Laboratory Result Reporting
^This data element is relevant for electronic PHCR only
§
The sending application and sending facility are included in the MSH segment in v2.x messages, and in
whatever control wrapper is used to send the document (which could be a v2.x message)
%
Confidential information must not be sent via email, unless secure transport has been pre-arranged
This draft review includes complex data elements. A complex data element includes a set of data
elements that (1) represent a single high-level concept, (2) always appear together and (3) are used in
more than one place in the common core data set. An example of a complex data element is a “person
name”, which is always composed of last (or family) name, first (or given) name, middle names/initials,
and suffix. For example, the “Person name” complex element is used to store information about the
subject of the report as well as the person making the report. Complex data elements have been
included to standardize content and make representation of the core lists consistent and
straightforward. Complex data elements may be mapped to formal HL7 complex data types, but the
primary purpose of this document is to enable review by both epidemiologists and information
technology specialists.
Table 1: Example Complex Data Elements for Case Reporting and Laboratory Result Reporting1
Complex Data Element Name
Identifier
Name (person)
Phone
Address
XXXXXXX [code]
1
Simple Data Elements included:
Identifier
Identifier assigning authority
Identifier type
Last name
First name
Middle name or initial
Suffix
Phone
Phone type
Street address
Second address line
City
State
Zip or postal code
County
Country
Address type
XXXXXXX, name
XXXXXXX, code
XXXXXXX, code system2
The example data elements in the table are a guide to show how complex data elements would appear. The
implementation guide will contain explicit instructions for complex data elements, based on standards
development organizations (e.g., HL7).
2
Code system version number will be included in the common core implementation guide