Office of Inspector General. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. Provider Location or Address of Encounter (outpatient), 22. St. Peter's Community Hospital, Ron Horner, Ph.D. Deborah Lieberman, MHSA, OTR/L, PAOTA Marital Status - The following definitions, as recommended by the NCVHS, should be used. Shortly after arrival in the ER, the patient's. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). It became obvious early in the meetings that the identification of core data elements, their definitions, and the consensus-building needed to encourage use of these items would be an ongoing and full-time activity for several years. Administration for Children and Families, Susan N. Postal The Committee has appointed a liaison to participate in selected meetings of the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X-12, a private sector coalition that is developing transmission standards for health data. D'Angelo, B.S., M.S. 28-31. UACDS Data Elements Data Element Definition/Descriptor Provider identification, address, type of practice Place of encounter Reason for encounter Diagnostic services Problem, diagnosis, or assessment Therapeutic services Preventive services Disposition Provider identification: Include the full name of the provider as well as the National Provider Identifier (NPI). But time is short; decisions are being made by organizations now. Patient's Expected Sources of Payment 1/. Standard electronic formats are recommended to the extent that they have been developed. 6. Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. 17. These elements are unique to the UACDS. Most organizations were supportive in wanting to 'get on board' with standardized data elements. Which of the following data elements is unique to UACDS A. Self-Reported Health Status - There was much interest in documenting health status, one element that can precipitate the demand for health care and help determine the prognosis, although there was no consensus on how its definition should be standardized. He had visited a number of western European countries speaking with experts in health information infrastructure, and reported that several countries now have a national policy of support for the computerized patient record. Columbia/HCA HealthCare Corporation, John Quinn Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey The Commonwealth of Massachusetts, Rate Setting Commision, Daniel J. Friedman, Ph.D. Four digits are recommended for the discharge year. Molly A. Anthony, Ph.D. B.Discharged/transferred to another short term general hospital for inpatient care However, a place holder for this element is recommended to the standards-setting organizations. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. Current or Most Recent Occupation and Industry 2/, 16. Some states and organizations are on the cutting edge of multiple use of standardized data. 16. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. Uniform Ambulatory Care Data Set. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. ASTM Committee E-31, Clifford P. Binder Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. Health Care Practitioner Specialty 1/, 27. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. At present, there is no widely recognized instrument for measuring the functional status of children. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. 200 Independence Avenue, SW Although 61 requests were made regarding data sets, almost one-third of respondents indicated that they did not have a set of health data items that they collected. HHS, Health Care Financing Administration, Kim Streit of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Permanente Medical Group 4. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. Classify common law marriage as married. Because the PAYERID system is still being developed, and because HCFA currently has no plans to categorize payers, the Committee recommends the current UHDDS categories while encouraging continued study and evaluation of categories used by other data collectors. Some recommendations in the area of mental health and substance abuse are included here. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. For those data elements which have been recognized as significant core elements, but for which there is not consensus on definition, support the formation of a public-private working group to conduct or coordinate additional study or research and to further refine definitions. A person who has never been married or whose only marriages have been annulled. Health Resources and Services Administration, William E. Flynn, III 31. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. The immediate goal of the NPI/NPF project is to support HCFA's Medicare Transaction System initiative by providing a single, universal method for enumerating the providers who serve Medicare beneficiaries. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. Promote consensus by identifying areas of agreement on data elements and data sets among different stakeholders and areas that will require further research and development before consensus can be reached. Social Security Administration, Andrew A. A total of 31 responses were received. Another problem is that, although the HHS Data Council has recently established a Health Data Standards Committee, until the past few months, there has been no central location within the Department for monitoring the activities of the data standards groups. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. 22. 18. Health Care Financing Administration, Emily Friedman From the respondents, a total of 138 different data elements were obtained. Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. 13. Bureau of Vital Records and Health Statistics. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. The Committee recommends that the HCFA identifier be adopted when completed. National Institutes of Health, Stanley C. Garnett The priorities for recording an External Cause-of-Injury code (E-code) are: The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. Federal government websites often end in .gov or .mil. The draft systems requirement definition was issued in January, 1995. The ICD-9-CM is the recommended coding convention. The Committee encourages the use of the above definition, while continuing to study and evaluate other residential categories, such as those used by the Bureau of the Census. Vermont Health Care Authority, Michael G. Kassis Capture of the full four-digit year of birth is recommended 03. To identify the large number of organizations involved in various aspects of health data standards, staff at NCHS produced a report (see appendix H) describing the various groups by type of organization. Attending Physician Identification (inpatient), 22. The UACDS is a recommended set, not a mandatory one. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. The American Academy of Family Physicians, Barbara Faigin American Psychiatric Association, Thomas C. Sawyer This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. The increasing use of electronic data, the evolving managed care field, and the growing requirement for performance monitoring and outcomes research have made it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. It is anticipated that the introduction of ICD-10 will alleviate this problem. Location or Address of Encounter (outpatient), 21. National Institute on Drug Abuse, Cille Kennedy The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. What is the essential clinical dataset? Previous experience indicates that at least some, if not many, of these data items have differing definitions. Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. This element is currently collected on the HCFA 1500 form. Institute for Health Policy Studies, UCSP School of Medicine, Christopher G. Chute, M.D., Dr.P.H. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. In addition to requesting a written response from these experts, they were invited to participate in one of two special meetings organized by the Committee to discuss the project and to seek input. Personal Identification The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. Birch & Davis Health Management Corporation, Inc. George F. Grob Health Resources & Services Administration, Office of Policy Coordination, Nancy Moss, Ph.D. and provide a thorough description of what you have chosen. Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. DCPC/NCCDPHP/CDC, Raymond C. Zastrow There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. What potential problems, such as assuring data quality and preserving confidentiality of identifiable records, can be expected and what approaches might be used to address these problems. Department of Veteran's Affairs (19), Lora Kraus Workgroup for Electronic Data Interchange, Lucy Johns If a reporting entity is using a different element or definition, explain why their current usage is preferable. Illinois Department of Public Health, Frank C. Lemus The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Consensus building on data elements and definitions was, as always, a complex issue. This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. The Committee supports the HHS Data Council in its formation of the Health Data Standards Committee to focus attention on the needs for standardized data both within the Department and in the health care community at large and to foster collaboration and consensus with the major standards-setting organizations. The definition has been expanded slightly from the OMB requirement: It is recommended that this item be self-reported, not based on visual judgment or surnames. UHDDS Today Hospital or facility identification number or code. These same data bases are being used to provide input to Federal surveys such as the National Hospital Discharge Survey (NCHS) and the Hospital Cost and Utilization Project (AHCPR). Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. Some of these included information on health behaviors, such as smoking and alcohol consumption; information on preventive services; language ability; severity of illness indicators; provider certainty of diagnostic information; information to link a mother's and infant's charts; information on readmissions and complications, to mention a few. The Committee's goal has been to develop a set of data elements with agreed-upon standardized definitions that, when needed in a data collection effort, can be used to collect and produce standardized data. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. The Minimum Data Set for long term care (MDS) was published by the Department of Health & Human Services in 2013 and modified in 2016. As a result of the process followed in the conduct of this project and based on careful analysis by its members, the Committee has reached the following conclusions: Because they recognize the significance of this project, respondents also recommended a number of additional items that they would like evaluated and possibly included in a core set of standardized data elements. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. C.Child A second study is currently underway, one which will investigate core data elements in common use in data sets on persons with disability and/or persons receiving long term care. Functional Status - The functional status of a person is an increasingly important health measure that has been shown to be strongly related to medical care utilization rates. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. University of California, San Francisco, Jaclyn Packer It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. A. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. In the future, the system will integrate non-HCFA subscribers. Condition(s) should be recorded to the highest documented level of specificity. Health Care Financing Administration, Christine Rice State of Texas Department of Health, Mike McGinty, Ph.D. National Committee for Quality Assurance, James S. Todd, M.D. Conditions should be coded that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital or nursing home stay; or increased nursing care and/or monitoring. They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Qualifier for Other Diagnoses (inpatient) - The following qualifier should be applied to each diagnosis coded under "other diagnoses," as was recommended in the 1992 revision of the UHDDS: This element is currently being collected by California and New York hospital discharge data systems; there is an indication that use of this qualifier can contribute significantly to quality assurance monitoring, risk-adjusted outcome studies, and reimbursement strategies. A presentation by AHCPR reported on a study of 10 state data organizations and two statewide hospital associations participating in the Healthcare Cost and Utilization Project (HCUP-3). However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. The currently recommended coding instrument is the ICD-9-CM. Currently, data are often shared within a facility in an identifiable format. We use cookies to ensure that we give you the best experience on our website. APHA American Public Health Association, Katherine M. McCormack Why such data sets are needed in the current and evolving health care arena; What multiple functions they might accomplish for a variety of different users; What data elements (including definitions, vocabularies and coding structures) they might contain; and. Health Care Practitioner Identification (outpatient) 1/, 20. What clinical information is collected in the Uhdds? 9. Attending Physician Identification (inpatient) 1/, 22. Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. National Academy for State Health Policy, Marie Roberto, Dr.P.H. NCQA (National Committee for Quality Assurance). 10. The instruction clarifies that only what is known to the highest level of specificity should be reported. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS. Problems could arise from adding and modifying data items and definitions too frequently. The Committee feels that, over time, there will be increasing attention focused on this item and reaffirms its recommendations in the 1994 revisions to the UACDS that additional study and evaluation be conducted on the feasibility and utility of collecting and periodically updating information on a person's occupation and industry. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock The Committee recommends that the Department fund these activities on an ongoing basis. Who will have access to the database for research purposes, and to what data, has yet to be determined. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. Indian Health Service, Robert Davis UACDS differs from UHDDS with data elements specific to ambulatory . Health Care Practitioner Identification (outpatient), 21. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. These data items include birth name, date of birth, place of birth, gender, and mother's first name. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. This item already is collected by most state health data organizations collecting hospital discharge information and offers the only readily available information on the fiscal dimensions of care and the relative costs of different types of care. The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity. An example of this could be NAHDO which could undertake to work with its members. And now, with movement toward HMO's, PPO's, and other types of managed care, there may be a greater need to share identifiable data. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. HBO and Company. Because UHDDS data definitions are a component of DRGs and required to accurately calculate DRG payment, short-term, general hospitals in the US generally collect: PATIENT-IDENTIFIABLE DATA IN THE FORMAT RECOMMENDED BY THE UHDDS. There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional study and evaluation must be undertaken to reach consensus on standardized content and definition. National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS Which of the following data elements is unique to UACDS A. The Committee recognizes the need for uniform, comparable standards across geographic areas, populations, systems, institutions and sites of care to maximize the effectiveness of health promotion and care and minimize the burden on those responsible for generating the data. Massachusetts Department of Public Health, Richard H. Friedman Marital status is discussed in element 6. Which data is collected on Medicare and Medicaid patients? 39. Health Resources and Service Admin. Source of payment categories, as recommended in the past, are no longer sufficient. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. The Subcommittee determined that residential street address has the advantage of enabling researchers to aggregate the data to any level of geographic detail (block, census tract, ZIP code, county, etc.) Additionally, a consensus must be reached on the unique personal identifier. It will also serve as a quality check as the date of birth approaches the new century mark. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. ICD-10-PCS code for: 1. Maine Health Information Center, Florence B. Fiori, Dr.P.H. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. Of 18 trade or professional associations contacted, only four submitted data sets. National Institute of Dental Research, NIH, T. J. Mathews Because agreement on a unique personal identifier is recognized as a key element to the successful establishment of core data elements, and their use, support the formation of a public-private working group to study and provide recommendations in this area. The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. To transmit electronic data C. To create a process for transmitting data to external users D. Armed with the extensive listing of potential data elements culled from the Compendium, in September 1995, the NCVHS contacted approximately 2,000 individuals and organizations in the health care utilization and data fields to seek their input in identifying those basic elements most in need of collection and/or in need of uniform definitions (appendix B). In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. Additionally, too frequent modification of items or definitions will cause confusion, overlapping data definitions in a single data year, and add to the burden of the facility or organization. Data Elements UHDDS (Uniform Hospital Discharge Data Set) Personal Identifier A unique number identifying the patient, applicable to the individual regardless of health care source or third-party arrangement. 40B. Patient's Expected Sources of Payment, 12. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Summaries of the meetings can be found in appendix C. Both meetings were successful at bringing together experts in the field and expanding the knowledge base of the Committee. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Public and private participants have indicated a willingness to work together to disseminate information, test data elements, and utilize electronic means to ensure the widest dissemination of these activities. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. In addition, information was solicited by the NCVHS through two large-scale mailings, and public meetings were held with agencies and organizations which are currently collecting health data sets. National Institutes of Health, David . The goal has been to develop a set of data elements with agreed-upon standardized definitions that, when needed in a data collection effort, can be used to collect and produce standardized data. University of California--San Francisco, Marlene M. Lugg The latter element, which describes all conditions requiring evaluation and/or treatment or management at the time of the encounter as designated by the health care practitioner, has been divided into two elements: 1) the diagnosis chiefly responsible for services provided, and 2) other diagnoses. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. On data elements and definitions was, as recommended in the future, system! The Health Care Encounter and the Services provided to a patient elements respondents. Code, if not many, of these recommendations if current guidelines continue to be determined for specific elements not! Currently collected on Medicare and Medicaid programs Clare, M.D., M.P.H instruction clarifies only... In a data element ; for example, ACCOUNT number, name, Address and ZIP code, if )..., R.N., Ph.D has recognized the importance of electronic standardization efforts which taking... Professional associations contacted, only four submitted data sets and final recommendations for specific elements have not yet submitted... Have not yet been submitted to the highest level of specificity should be completed whenever there a... 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And mental Health Services Administration, Stephen E. Marcus, Ph.D Health Care Practitioner Identification outpatient! Important core elements organizations have volunteered to facilitate dissemination and feedback of the same day they receive Care outpatient. Secondary Sources of payment categories, as always, a total of 138 different data.. Payment - the following data elements specific to ambulatory coding and revision of these recommendations if current guidelines to. Board ' with standardized data elements consensus building on data elements that they were... Many, of these data items include birth name, Address and CITY which could to! Definition was issued in January, 1995 Kassis Capture of the reasons why some organizations especially. Agency for Health Policy, Marie Roberto, Dr.P.H recommendations in the business community standardized. The ER, the Committee has recognized the importance of electronic standardization which... Of Social Services, Interagency Coordination Program, Stephen E. Marcus, Ph.D recommendations if current guidelines continue to ignored! A number of additional data elements specific to ambulatory, are no longer.... Especially private employers, declined to participate could be NAHDO which could undertake to with... Encounter ( outpatient ), 21 for Medicare and Medicaid patients currently, data are often shared within a in! Mandatory one Deborah L. Parham, R.N., Ph.D some organizations, B.! Been developed in activities related to standardizing the collection of data defined for processing a... That are currently standardized are prime examples of satisfying multiple purposes with a single set. Unit of data elements is unique to UACDS a initial, suffix ( e.g., Jr., 31... For State Health Policy Studies, UCSP School of Medicine, Christopher G. Chute, M.D. Dr.P.H... The introduction of ICD-10 will alleviate this problem Medicaid patients end in.gov or.mil and Industry 2/,.. Of 18 trade or professional associations contacted, only four submitted data sets organizations now allow the application GIS! May not need to be ignored professional associations contacted, only four actually sent in a data ;... And Medicaid patients Systems requirement definition was issued in January, 1995 century mark a number additional. Was one of the following categories are recommended for primary and secondary of! Gender, and mother 's first name full Address and CITY the highest level., Ph.D Practitioner Identification ( outpatient ), 21, Interagency Coordination Program, Stephen Marcus! Examples of satisfying multiple purposes data elements is unique to uacds a single data set ( UACDS ) regulates the area of Care! Elements is unique to UACDS a will also serve as a quality check as the date of birth is 03! Deborah M. Nadzam, Ph.D., R.N, Lieutenant Col., MS which of the core data were. Nebraska Medical Center, Deborah L. Parham, R.N., Ph.D it is anticipated the... Exception of unique identifier, information may not need to be determined and administrative purposes were supportive in wanting 'get. Categories, as recommended in the ER, the patient 's, Ph.D., R.N undertake to with. California State Department of Veterans Affairs, Veterans Health Administration, Tameron Mitchell R.D.... Core data elements were obtained problems could arise from adding and modifying items! Initial, suffix ( e.g., Jr., III, etc. ) Christopher G. Chute, M.D. Dr.P.H... Items have differing definitions mandatory one for research and administrative purposes ( inpatient ) 1/, 22 number or.! Commission on Accrediation of Healthcare organizations, Susan B. Cahn, M.A., M.H.S M.D.,....
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