PERSON serves as the central identity management for all persons in the database. It contains records that uniquely identify each person or patient, and some demographic information.

• age
• race
• ethnicity
• sex
• provider (current PCP from patient.CUR_PCP_PROV_ID)

DEATH data is sourced from a combination of the electronic health record (EHR) and from periodic loads from North Carolina State Death Registry.

• date
• cause of death

VISIT_OCCURRENCE contains events where persons engage with the healthcare system for a duration of time. They are often also called "Encounters."

• encounter start/end date
• visit type (emergency, inpatient, emergency-to-inpatient, outpatient, telehealth)
• care site (primary department from pat_enc.effective_department_id)
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class. (This is equivalent to PCORnet encounter.PROVIDERID).

VISIT_DETAIL represents details of each record in the parent VISIT_OCCURRENCE table. An example of this would be the movement between units in a hospital during an inpatient stay or claim lines associated with a one insurance claim.

• inpatient sub-encounters
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class. (This is equivalent to PCORnet encounter.PROVIDERID).

CONDITION_OCCURRENCE contains records of events of a person suggesting the presence of a disease or medical condition. Diagnoses are included in CONDITION_OCCURRENCE. Note that OMOP uses SNOMED to identify diagnoses; if you are more familiar with using ICD-9 and ICD-10, TraCS staff can provide further information and mapping between the two vocabularies.

• hospital final/discharge
• physician billed
• admission
• clinical/encounter
• hospital problem list
• problem list
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class. (This is equivalent to PCORnet encounter.PROVIDERID).

DRUG_EXPOSURE represents data related to exposure to a drug ingested or otherwise introduced into the body (medications and immunizations).

• prescriptions/ordered medications/immunizations
• date of order
• refills
• quantity
• days supply
• frequency (in sig field)
• route
• Provider: this field contains the authorizing provider. (This is equivalent to PCORnet prescribing.RX_PROVIDERID or medadmin.MEDADMIN_PROVIDERID or immunization.VX_PROVIDERID or procedures.PROVIDERID; PCORnet prescribing and medadmin providers are from clarity order_med.AUTHRZING_PROV_ID and immunization providers are from clarity IMMUNE.GIVEN_BY_USER_ID.

PROCEDURE_OCCURRENCE contains records of activities or processes ordered by, or carried out by, a healthcare provider on the patient with a diagnostic or therapeutic purpose.

• billed procedures
• procedure date
• Provider: This contains procedure service or billing provider. (This is equivalent to PCORnet procedures.PROVIDERID. PCORnet procedures providers are from clarity arpb_transactions.serv_provider_id or arpb_transactions.billing_prov_id or hsp_acct_cpt_codes.CPT_PERF_PROV_ID or hsp_acct_px_list.PROC_PERF_PROV_ID or hsp_transactions.performing_prov_id or hsp_transactions.billing_prov_id.)

MEASUREMENT contains records of Measurements, i.e. structured values (numerical or categorical) obtained through systematic and standardized examination or testing. The MEASUREMENT table contains both orders and results of such Measurements as laboratory tests and vital signs.

• lab results (LOINC coded labs ONLY)
• vitals: height, weight, BP, BMI, SpO2, FiO2, birth weight, birth GA
• date of measurement
• measured value
• units

OBSERVATION captures clinical facts about a Person obtained in the context of examination, questioning or a procedure. Any data that cannot be represented by any other domains, such as social and lifestyle facts are recorded here.

• misc. - dx, procedure, labs
• expanded demographics - patient preferred spoken language, gender identity, sexual orientation, marital status (flowsheet data at encounter level and patient level)
• health behaviors - smoking, tobacco
• patient-level SDOH (from flowsheets & social_hx table covering Stress, Transportation, Financial Resource Strain, Food Insecurity, Social Connection, Intimate Partner Violence, Physical Health, Isolation, Health Literacy) and PRO_CM (PHQ-2, PHQ-9, GAD-7, AUDIT-C, Edinburgh Postnatal Depression Scale)
• allergies

When a baby is born within the UNC Health System, a linkage between the records of the mother and the baby are retained.

• mom/baby relationship

PROVIDER contains a list of uniquely identified healthcare providers. These are individuals providing hands-on healthcare to patients, such as physicians, nurses, midwives, physical therapists etc.

• NPI
• provider specialty (first listed in the case of multiple specialty)
• provider gender

CARE_SITE contains a list of departments and associated department details. Also see Care Site view in SIDECAR section of this document

• Care site name (department name)
• Place of Service source value contains PCORnet's clinic/department types (ex: HOSPITAL_OUTPATIENT_ENDOCRINOLOGY_CLINIC)
• Location (see location table for columns available)

Currently only patient location is captured

• City
• State
• ZIP
• County
• does NOT include street address

DEVICE_EXPOSURE contains records of exposure to any medical device, instrument, equipment, or material used for diagnostic or therapeutic purposes. Currently, only some oxygen device / supplementation data is captured (ex: CPAP, nasal cannula, ventilator, etc.)

• Device exposure start date and time
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class
• Device exposure name

The following commonly needed data are not available in the OMOP CDM. TraCS may be able to support you in receiving these data through a Standard Epic Clarity request or through a Custom request. Please discuss with the project manager doing your request intake.

• Visit details
  • ADT
  • Future Appointments
  • No shows

• Geodata
  • Latitude, Longitude
  • Census Tract
  • RUCA
  • SVI

• Diagnosis Priority other than primary discharge diagnosis
• Procedure Orders: Clarity ORDER_PROC details
• Flowsheet data not captured in PCORnet vitals, obs_gen, obs_clin or pro_cm
• Obstetrics data except mom baby relationship and gestational age
• Notes
• Imaging data

A condition represents a patient's diagnosed and self-reported health conditions and diseases. The patient's medical history and current state may both be represented. Allergies are included. [Includes ADS & Epic data: 2004-latest refresh date]

• hospital problem list
• patient problem list
• condition report date, resolved date, onset date

Reported mortality information for patients pulled from the patient's UNC Health medical records and State Death Data record from the North Carolina Department of Health and Human Services (NCDHHS). State Death Data Policy applies. [Includes only Epic data: 04/04/2014-latest refresh date]

• date of death
• source of death data, either L (Other, locally defined) or S (State Death files)
  • L (Other, locally defined): [Includes only Epic data: 04/04/2014-latest refresh date]
  • S (State Death files): [Includes only Epic data: 04/04/2014- 12/31/2022, latest finalized State Death Data]

The individual causes associated with a reported death pulled from the patient's UNC Health medical records and State Death Data record from the North Carolina Department of Health and Human Services (NCDHHS). State Death Data Policy applies. [Includes only Epic data: 04/04/2014-latest refresh date]

• ICD 9 or 10 Code for cause of death (may have multiple causes per patient)

Demographics record the direct attributes of individual patients. [Includes ADS & Epic data: 2004-latest refresh date]

• Date of Birth
• Sex
• Sexual orientation
• Gender identity
• Ethnicity [available beginning 2010]
• Race
• Preferred language spoken

Diagnosis codes indicate the results of diagnostic processes and medical coding within healthcare delivery. Data in this table are expected to be from healthcare-mediated processes and reimbursement drivers. [Includes ADS & Epic data: 2004-latest refresh date]

• hospital final/discharge
• physician billed
• admission
• clinical/encounter
• external injuries
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class. (This is equivalent to PCORnet encounter.PROVIDERID).

Prescriptions filled through a community, mail-order or hospital pharmacy. Outpatient dispensing may not be directly captured within healthcare systems.

Encounters are interactions between patients and providers within the context of healthcare delivery. [Includes ADS & Epic data: 2004-latest refresh date]

• encounter start/admit and end/discharge date/time
• encounter type (emergency, inpatient, emergency-to-inpatient, outpatient, telehealth, etc.)
• facility ID and type (primary department from pat_enc.effective_department_id) [available only on Epic from 04/04/2014]
• Provider: encounters are assigned visit provider, discharge provider, attending provider or admission provider based on encounter types and patient base class.
• primary and secondary payer type (using hospital and physician billing)

Enrollment is a concept that defines a period of time during which a person is expected to have complete data capture. This concept is often insurance-based, but other methods of defining enrollment are possible. We use encounter-based information. [Includes ADS & Epic data: 2004-latest refresh date]

• Enrollment start date = minimum admit date (from Encounter table)
• Enrollment end date = maximum admit date (from Encounter table)

Records of immunizations that have been delivered within the health system as well as reports of those administered elsewhere (e.g. State Immunization Record). [Includes only Epic data: 04/04/2014-latest refresh date]

• Administration date
• Code & code type (i.e. CPT/HCPCS, RXNORM, CVX, etc)
• Dose & unit
• Lot number
• Expiration date

Table for storing historical information about units of measure and reference ranges for laboratory test results.

This table is used to store quantitative and qualitative measurements from blood and other body specimens. [Includes ADS & Epic data: 2004-latest refresh date]

• Specimen Source
• LOINC Code for Lab Test
• Test Priority
• RESULT_LOC: Result Location like Lab or Point of Care
• Date When the Lab Test Was Ordered
• Date When the Specimen Was Collected
• Time When the Specimen Was Collected
• Date When the Lab Result Was Reported
• Time When the Lab Result Was Reported
• Qualitative Lab Result. e.g. Negative, Positive, Color, or Category
• Numeric Value of the Lab Result, including modifiers, like = < >
• Unit of Measurement for the Lab Result
• Reference Ranges, High, Low
• Abnormal Indicators

Longitudinal record of a patient's address that adheres to the requirements of a Limited Data Set. [Includes only Epic data: 04/04/2014-latest refresh date]

• City
• State
• Zip5, only 5 digit postal codes are available
• County, limited availability
• Address Use Start Date
• Address Use End Date

Records of medications administered to patients by healthcare providers. These "administrations may take place in any setting, including inpatient, outpatient or home health encounters." UNC only includes Medication Administration from Inpatient Hospital settings. [Includes ADS & Epic data: 2004-latest refresh date]

• Medication Code: The NDC or RxNorm of the Medication
• Medication Start Date: Start date of the medication administration
• Medication Start Time: Start time of the medication administration (if available)
• Medication Stop Date: End date of the medication administration
• Medication Stop Time: End time of the medication administration (if available)
• Medication Dose: Amount of medication administered
• Medication Dose Unit: Unit of measurement for the medication dose
• Medication Route: Route of administration (e.g., oral, intravenous)

Standardized qualitative and quantitative clinical observations about a patient , including vital signs. For more detailed information, please click on table name. [Includes only Epic data: 04/04/2014-latest refresh date]

• vitals from flowsheets: temperature, heart rate, respiratory rate, SaO2 (O2 saturation),FiO2
• vaping and e-cigarettes
• birth weight

Table to store everything else/ general observations. For more detailed information, please click on table name. [Includes only Epic data: 04/04/2014-latest refresh date]

• PCORnet data elements: Admissions to ICU, mechanical ventilation
• gestational age
• N3C Data Enhancements:
  • ADT Events (ICU, ED, all other IP)
  • O2 Devices
  • Long-COVID clinic
  • patient-level SDOH (from flowsheets & social_hx table covering Stress, Transportation, Financial Resource Strain, Food Insecurity, Social Connection, Intimate Partner Violence, Physical Health, Isolation, Health Literacy, Marital Status)

Patients who are enrolled in PCORnet clinical trials and PCORnet studies. [Includes only Epic data: 04/04/2014-latest refresh date] The PCORnet Trial table is only available to studies that populated it and then only subjects that are enrolled for their study.

• Trial Identifier
• Participant Identifier
• Trial Site Identifier
• Trial Enrollment Date
• Trial End Date
• Trial Withdrawal Date
• Trial Invitation Code

Provider orders for medication dispensing and/or administration. These orders may take place in any setting, including the inpatient or outpatient basis. [Includes ADS & Epic data: 2004-latest refresh date]

• Prescribed Medication Code as RxNorm
• Prescribing Provider (See Provider)
• Prescription Order Date
• Prescription Order Time
• Prescription Start Date
• Prescription End Date
• Ordered Dose of Medication
• Unit of Measurement for Dose
• Quantity of Medication Prescribed
• Form of Medication (e.g., tablet, liquid)
• Number of Refills Authorized
• Frequency of Medication Administration
• As Needed (PRN) Flag
• Route of Administration (e.g., oral, intravenous)

This table is used to store responses to patient-reported outcome measures (PROs), surveys, and questionnaires. This table can be used to store item-level responses as well as the overall score for each measure. We currently are only bringing in overall scores and PROs that have a LOINC code available for the question, answer, or score.[Includes only Epic data: 04/04/2014-latest refresh date]

• Date PRO was recorded in flowsheet
• Measure Scores: AUDIT-C Score, GAD-7 Total Score, PHQ-2 Total Score, PHQ-9 Total Score, Edinburgh Postnatal Depression Scale Total
• PROs/Questionnaires/ Surveys: AUDIT-C, GAD-7, PHQ-2, PHQ-9, Edinburgh Postnatal Depression Scale

Procedure codes indicate the discreet medical interventions and diagnostic testing, such as surgical procedures and lab orders, delivered within a healthcare context. [Includes ADS & Epic data: 2004-latest refresh date. Hospital billed CPT from 2004 while physician billed CPT from 2008]

• Procedure Date: Date when the procedure was performed
• Procedure Code: The coded procedure performed
• Procedure Type: Type or category of the procedure (CPT, ICD09, and ICD10 Procedures)
• Provider: The performing provider (see Provider)

Data about the providers who are involved in the care processes documented in the CDM. [Includes only Epic data: 04/04/2014-latest refresh date]

• Provider sex
• Provider primary specialty
• Provider NPI

Vital signs (such as height, weight, and blood pressure) directly measure an individual's current state of attributes. [Includes ADS & Epic data: 2004-latest refresh date]

• Height
• Weight
• Original Body Mass Index (kg/m²)
• Blood Pressure:
  • Diastolic Reading
  • Systolic Reading
• Smoking Status
• Tobacco Use
• Tobacco Type

Each vital sign is recorded as a row per measurement date.

The following commonly needed data are not available in the PCORnet CDM. TraCS may be able to support you in receiving these data through a Standard Epic Clarity request or through a Custom request. Please discuss with the project manager doing your request intake.

• procedure orders
• flowsheet data not captured in PCORnet vitals, obs_clin, obs_gen or pro_cm
• future appointments
• facility location
• Prescribing Days Supply