Date of the Report

The date on which the reporting party (e.g., physician, nurse practitioner, physician assistant, etc.), completes collection of minimum data for the eICR

Used to assess timelines of eICR data provisioning, and other quality assurance tasks

Report Submission Date/Time

The date and time at which the EHR system sends the eICR data to the jurisdictional PHA or designee

Used to ensure timeliness of report and to identify time lags between date of the report and when the EHR sends the report

Sending Application

The name of the sending application

Used to ensure quality and integrity of eICR data

Provider ID

Identification code for the care provider (e.g., National Provider Identifier (NPI))

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Provider Name

The first and last name of the healthcare provider

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Provider Phone

The provider's phone number with area code

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Provider Fax

The provider's fax number with area code

Necessary to obtain additional info during case follow-up phase or to submit supplemental information

Provider Email

The provider's email address

If secure email is available; used for sharing secure links to health data if allowed by state regulations

Provider Facility/Office Name

The provider facility's full name, not necessarily where care was provided to patient

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Provider Address

The geographical location or mailing address of the provider's office or facility. Address must include street address, office or suite number (if applicable), city or town, state, and zip code

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Facility ID Number

Identification code for the facility (e.g., Facility NPI)

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Facility Name

The facility's name

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Facility Type

The type of facility where patient received or is receiving healthcare for the reportable condition (e.g., hospital, ambulatory, urgent care, etc.)

Used to determine the type of care setting in which patient is receiving care for the reportable condition

Facility Phone

The facility's phone number with area code

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Facility Fax

The facility's fax number with area code

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Facility Address

The mailing address for the facility where patient received or is receiving healthcare for the reportable condition. Must include street address, city/town, county, state, and zip code

Need provider's contact information in order to follow up appropriately for reportable event to ensure appropriate treatment, identify contact exposures, etc.

Patient ID Number

Patient social security number, medical record number, or other identifying value as required or allowed under jurisdictional laws governing health data exchange

Identification and contact; jurisdictions may select which they can receive based on laws governing public health data exchange

Patient Name

All names for the patient, including legal names and aliases. Must include the name type (i.e., legal or alias), first name, middle name, and last name

Identification and contact

Parent/Guardian Name

All names for the patient’s parent or guardian, including legal names and aliases (if patient age is < 18 years). Must include name type (i.e., legal or alias), first name, middle name, and last name

For appropriate contact with minors

Patient or Parent/Guardian Phone

All phone numbers and phone number types for the patient or parent/guardian

Contact Patient

Patient or Parent/Guardian Email

The email address for the patient or the patient’s parent/guardian.

Contact Patient

Street Address

All addresses for the patient, including current and residential addresses. Must include street address, apartment or suite number, city or town, county, state, zip code, and country

Case Assignment, analysis and visualization, matching

Birth Date

The patient's date of birth

Appropriate identification, appropriate identification of minors, risk; Necessary to determine patient age; matching electronic laboratory reports (ELRs)

Patient Birth Sex

The patient's biological sex (not gender)

Demographic reporting

Race

The patient's race

Demographic reporting

Ethnicity

The patient's ethnicity

Demographic reporting

Preferred Language

The patient's preferred language

Communication with Patient

Current Occupation

Occupation which the subject currently holds.

Identification of potential risk, transmission risk

Usual Occupation

The occupation which the subject has held for the longest duration through his or her working history.

Identification of potential risk, transmission risk

Current Industry

Type of business (industry) in which the subject currently holds a job.

Identification of potential risk, transmission risk

Usual Industry

The industry (type of business) which the subject has worked in for the longest duration while in the usual occupation

Identification of potential risk, transmission risk

Current Job Title

Title of the currently held job.

Identification of potential risk, transmission risk

Current Employer Name, Phone, and Address

Name, phone, and address of the current employer.

Identification of potential risk, transmission risk

Occupational Exposure

Actual contact or interaction with a specific hazard at work that increases an individual’s risk of a detrimental physical or mental health outcome.

Identification of potential risk, transmission risk

Pregnancy status (yes, no, possible, unknown)

The patient's pregnancy status.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Pregnancy status determination method

The method by which the pregnancy status was determined.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Pregnancy status recorded date

The date on which the pregnancy status was recorded.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Estimated date of delivery (EDD)

Estimated date a woman will give birth.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Estimated date of delivery (EDD) method

The method used to determine the EDD.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Estimated gestational age

The estimated gestational age of the pregnancy (in contrast to the gestational age at birth), beginning from the time of fertilization.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Estimated gestational age determination date

The date the gestational age was determined.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Estimated gestational age determination method

The method used to determine the gestational age.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Last menstrual period (LMP)

Start date of the last menstrual period of the patient.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Pregnancy outcome

The result(s) of the pregnancy, such as live birth, still birth, miscarriage, etc.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Pregnancy outcome date

Date on which the pregnancy outcome occurred.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Postpartum status

The postpartum status of a patient. If the template is present, the patient is in the postpartum period.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Visit Date/Time

Date and time of the provider's most recent encounter with the patient regarding the reportable condition

Defines when the individual may have been ill; a point in time to which can link other potential cases of reportable event; necessary to ensure follow-up within key time frames/helps triage priority follow-up and ensure control measures are implemented in a timely way

Admission Date/Time

Date and time the patient was admitted to the treatment facility; e.g., hospital

Key for epidemiologic investigation - important to know if hospitalized for severity of condition and to triage priority follow-up

History of Present Illness

Physician’s narrative of the history of the reportable event. Information about possible contacts and/or exposures may be captured here.

Indicator of reportable condition - most important descriptor of condition/ epidemiologic information - supports epidemiologic investigation; epidemiologic relevant information

Reason for Visit

Provider’s interpretation for the patient’s visit for the reportable event

Indicator of reportable condition - most important descriptor of condition/ epidemiologic information - supports epidemiologic investigation

Chief Complaint

Patient’s chief complaint (the patient’s own description)

An early indicator of a possible reportable condition

Past Medical History

A record of the patient’s past complaints, problems, and diagnoses.

Provides information on patient’s previous conditions or diagnoses that could be relevant to the current condition, such as underlying conditions.

Review of Systems

A relevant collection of symptoms and functions systematically gathered by a clinician (includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing).

If clinical details signify a possible case of public health importance - confirm the need for public health follow up

Date of Onset

The date of symptoms for the reportable event

Helps determine possible exposure and illness- calculate incubation period

Symptoms (list)

List of patient symptoms (structured) for the reportable event

If clinical symptoms signify a case of public health importance - confirm the need for public health follow-up

Laboratory Order Code

Ordered tests for the patient during the encounter

Some lab test orders are reportable for suspected cases

Laboratory Result

The result of a laboratory test for the patient during the encounter

Some lab test results are reportable for suspected cases

Laboratory Result Status

The status of a laboratory test (preliminary, final etc.)

Indication of test completeness and reliability of results.

Specimen source/type/id/collection date

Information about the specimen collected

Additional details on laboratory specimen needed to confirm some conditions (e.g., collected from a sterile site)

Placer Order Number

Identifier for the laboratory order from the encounter

Potential value to linking electronic laboratory reports (ELR) to eICR

Diagnoses (list)

The healthcare provider's diagnoses of the patient's health condition (all)

If clinical diagnoses signify a case of public health importance - confirm the need for public health follow-up

Date of Diagnosis

The date of provider diagnosis

Knowing when patient is diagnosed; integral to epidemiological investigation

Medications

Medications relevant to the reportable event (includes admission, administered, historical, planned medications)

To find treatments that were prescribed; prophylaxis; knowing if the patient has already been treated, lower on the list for public health (priority)

Death Date

The patient's date of death

Patient follow-up and epidemiological purposes

Patient Class (Encounter Type)

Whether patient is outpatient, inpatient, emergency, urgent care

Indication of possible severity of condition

Travel History

The patient's travel history, includes purpose of travel, dates of travel, locations of travel, details of transportation (ship, plane, etc.)

Risk, potential severity of action, timeliness of action (e.g., is travel history relevant); Prioritization and triaging

Vital Signs

The patient's relevant vital signs.

Indication of possible severity of condition

Therapeutic Medication Response

The therapeutic response to a medication (as opposed to an undesired reaction). e.g., Positive response to naloxone administration after a suspected naloxone administration.

Confirmatory response can be indicative of suspected condition.

Homeless

The patient's homeless status.

Risk indicator; important health equity indicator

Immunization Status

The patient’s current immunization status and pertinent immunization history.

Risk, potential severity of action, timeliness of action

Vaccine Credential Patient Assertion

Whether or not the patient has asserted that they have verifiable vaccine credentials.

Indicator of vaccine history

Gender Identity

The patient's gender identity. (Different from patient gender (administrativeGender) and birth sex).

Demographic reporting

Procedure

Interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the encounter.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Planned Procedure

Interventional, surgical, diagnostic, or therapeutic procedures or treatments planned as a result of the encounter.

Appropriate treatment, follow-up, appropriate for scoring/risk ascertainment

Disability Status

A set of questions used to measure disability.

Risk indicator; important health equity indicator

Emergency Outbreak Information

Information that is required during a public health emergency/outbreak.

Risk indicator; ability to share critical information with public health associated with an outbreak

Exposure/Contact Information

Potential patient exposure and contact information.

Risk indicator

Tribal Affiliation

The name of a patient’s affiliated tribe and whether or not the patient is an enrolled member.

Demographic reporting; important health equity indicator

Country of Nationality

Country of nationality (when patient has recent travel history).

Demographic reporting

Country of Residence

Country of residence (when patient has recent travel history).

Demographic reporting

Reportability Response information

This information does not come from the healthcare organization/EHR.

For PHA internal use only: Information from a Reportability Response that was generated in response to the eICR.