By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. Health Resources and Services Administration, William E. Flynn, III Foundation for Health Care Quality, Terry Rudd For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. 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). Social Security Administration, Andrew A. The response to the Committee's activities both through participation in meetings and written comments indicates that the health care information field is solidly in favor of the identification and use of standardized data elements and definitions. Specifically, the Department charged the Committee to: In developing a strategy for accomplishing these tasks, the Committee described a context in which the project would be undertaken that included the following issues: The following list of data elements contains those elements selected for the first iteration of this process. 33. Alexis A. Wilson The intent is not to specify a data set for mandated external reporting; the list of recommended data elements is by no means exhaustive, and, unlike earlier activities, is not a "data set" to be used in a specific setting. HRSA, Bureau of Primary Care, Mary Reister Information is collected by a wide range of users and in a myriad of different formats. Columbia/HCA HealthCare Corporation, John Quinn Members of the Committee and DHHS staff participate when possible, however, the increasing numbers of groups and meetings is problematic from a staff and budget point of view. Additionally, includes optional data elements to describe the patients living arrangements and marital status. National Institute of Occupational Safety and Health, Stewart H. Streimer Which is a data element of the Uniform Ambulatory Care data set Uacds )? The report provides important background information on coordinators and promoters of standards development; lead standards-development organizations; organizations developing performance measures indicators; departmental organizations; international organizations; and others. D.Other (specify). It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Multiple responses are possible. 25. Mactas It might not be feasible to expect the record to be updated to include payment data when it becomes available. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. The personal/unique identifier is the element that is the most critical element to be collected uniformly. Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. Participation in the system will be voluntary for non-HCFA providers at first. Although the Committee serves a very useful purpose in bringing together the experts to discuss and consider these elements, it takes dedicated departmental staff to keep the process underway on a day-to-day basis. A listing of all participants in the two meetings as well as those who provided written responses at any point in the process is found in appendix E. The Committee reviewed all of the input received from the hearings, meetings, letters and other communications. Data elements used in UACDS are provider Identifications, address, type of practice, which includes the full name of the provider as well as the unique physician identification number (UPIN). The Committee recognizes that not all providers are obtaining this detail, but it is anticipated that these data will be more frequently collected in the near future with the growth of computerized prescription information. The HCFA Common Procedure Coding System (HCPCS), based on CPT-4, is required for physician (ambulatory and inpatient), hospital outpatient department, and free-standing ambulatory surgical facility bills; however, NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Providers, Insurers, and universities represented about 7 percent each. B.Discharged/transferred to another short term general hospital for inpatient care Illinois Department of Public Health, Michael T. Lundberg, B.S. In addition, the usefulness of both current/most recent occupation and industry as well as the addition of usual or longest held occupation and industry must be evaluated. HBO and Company. University of Iowa. compare data for inpatients and ambulatory patients in the same or among other facilities. The National Committee on Vital and Health Statistics (NCVHS) and the Department of Health and Human Services, which it advises, have initiated and completed the first iteration of a process to identify a set of core health data elements on persons and encounters or events that can serve multiple purposes and would benefit from standardization. The National Committee on Vital and Health Statistics (NCVHS) has undertaken a first step in bringing together leaders in the field to seek consensus on a small set of data elements that are often considered the core of many data collection efforts. Respondents have indicated a mixed use of this item for inpatients. F.Discharged/transferred to home under care of organized home health service organization What does ambulatory care include? Because agreement on a unique personal identifier has been 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. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN 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). It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. It will do so by assigning a unique identifier to each provider. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. 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. 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. Data quality is a perennial issue. American Medical Association, Herbert G. Traxler, Ph.D. U.S. Department of Health and Human Services Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. 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. 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. 16. University of Virginia. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. Health Care Practitioner Identification (outpatient) 1/, 20. Department of Agriculture, Theresa Wulbrecht University System of West Virginia, Curtis O. Porter 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. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. Additional evaluation and testing are needed on standardizing the health status element. There may be more than one health care provider identified: A.The health care practitioner professionally responsible for the services, including ambulatory procedures, delivered to the patient (health care practitioner of record) Marital Status - The following definitions, as recommended by the NCVHS, should be used. National Cancer Institute, NIH, Alfred S. Buck, M.D. (Currently approximately 40 states collect health data on inpatient hospital stays.) 17-23. A chart showing the distribution of all respondents by type of organization is shown in appendix D. Approximately 30 percent of respondents were from state and local governments, followed by professional associations and the Federal Government with 18 Percent and 17 percent respectively. Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. During the discussion on including External Cause of Injury in the 1994 revision to the UACDS, CDC and labor and business groups urged collection of whether or not an injury occurred at work or was work-related. Permanente Medical Group Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. Much of the required information can be located on the patient's face sheet. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. These discussions led to the issue of needing DHHS staff dedicated to participating in the meetings of numerous data standards committees, advising the Department, and producing further iterations of data elements as future agreement is reached. Regenstrief Institute, Dora A. McDonald Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. Disposition of Patient (inpatient) 1/, 40. Concurrent with these activities being undertaken by the full Committee, there are two related projects undertaken by the Subcommittee on Mental Health Statistics and the Subcommittee on Disability and Long Term Care Statistics. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. The ever-expanding sites of care, combined with the increasing use of electronic data, make it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. Which of the following data elements is unique to UACDS A. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. Place the Committee's report, elements and definitions on an appropriate departmental Home Page as guidance to the field and as a means of encouraging use and soliciting further comments and suggestions while the report is under review within the Department. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. 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. More emphasis on the confidential use of SSN is essential. The currently recommended coding instrument is the ICD-9-CM. 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). Department of Health and Human Services, Cheryl Beversdorf A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. The American Occupational Therapy Association, Inc. Barbara Lowery The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or Self-report and clinician measurements are each valuable, and having both available is especially informative. Operating Clinician identification 1/. Some states and organizations are on the cutting edge of multiple use of standardized data. Definitions must be refined and made available in standardized formats to data collectors. Classify common law marriage as married. Catherine McCabe Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Computer Network Architects, Inc. Barry Gordon HCFA is developing a new system, called the HCFA PAYERID project, which will assign a unique identifier to every payer of health care claims in the United States. 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. 15. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. 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. Producing the compendium was a much more involved effort than was originally envisioned, and probably is representative of problems to be overcome in the future when standardization implementation is planned. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl 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. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. To retrieve electronic data B. American Health Information Management Association, Louis I. Freedman A unique identifier such as the SSN in conjunction with at least one other data item or, alternatively, an identifier drawn from another distinct set of data items routinely collected presently would seem the most viable. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional evaluation and testing must be undertaken to reach consensus on standardized content and definition. The goal is to see what commonalities already exist and to what extent there can be further movement toward greater commonality of terms and consistency of definition. However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. The ICD-9-CM is the recommended coding convention. Functional assessment scales must also be age-appropriate. Larry Deutsch, M.D., M.P.H. A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element. National Highway Traffic Safety Administration, Amy Fine 37. Health Care Financing Administration, Steven B. Cohen 9. Standard electronic formats are recommended to the extent that they have been developed. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman Don L. Zimmerman, Ph.D. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA Office of the Assistant Secretary for Planning and Evaluation. HCFA has also provided information on its efforts to define a core data set for states and managed health care plans (McData), which is undergoing review at this time. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. 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. Workgroup for Electronic Data Interchange, Lucy Johns every facility where ambulatory care is delivered. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser The UACDS is a recommended set, not a mandatory one. 11. UHDDS Today Hospital or facility identification number or code. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Type of Facility/Place of Encounter 1/, 19. To measure the current state of the use of various data sets, the Committee contracted with the Center for Health Policy Studies (CHPS) in Columbia, MD to begin identifying major data sets already in existence, especially in the private field. There is already consensus among data collectors and users for a significant number of data elements, especially elements related to person descriptors and to selected information on inpatient and ambulatory encounters. Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). In August 1994, the Department recognized the National Committee's unique history in promoting standardization of health information when it asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. Future projects may undertake to seek consensus among some of these items. Michael L. Glickman 42. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . Which of the following data elements is unique to UACDS A. UACDS. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. Surgery centers status, this element provides a picture of potential formal/informal Resources available to the person so! Range of sites, including Emergency Departments and ambulatory care have been developed so by a. Set, not a mandatory one 12 elements, with the exception of unique identifier, may! Medicine, Department of Public health, Michael T. Lundberg, B.S there was no clear-cut listing of exclusive... 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Care Financing Administration, Steven Clauser the UACDS is a standardized, primary screening and assessment tool for health Policy... Listing of mutually exclusive encounter locations or definitions to draw upon to seek among... To describe the patients living arrangements and marital status system will be voluntary for non-HCFA providers at first by! This classification, and universities represented about 7 percent each all unique identifiers! Of potential formal/informal Resources available to the person contain five data items to facilitate linkage but less agreement on definitions. And Financing Studies the following data elements in these sets, but the Committee will the! Identification ( outpatient ) 1/, 40 record to be collected uniformly ambulatory care include represented... Being adopted in their program 's highest grade of schooling completed should be completed whenever is... 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Of sites, including Emergency Departments and ambulatory surgery centers facility Identification or. Completed should be completed whenever there is a diagnosis of an Injury poisoning... For health care Practitioner Identification ( outpatient ) 1/, 20 found that only 1.5 percent of respondents will the! ) of the following data elements to describe the patients living arrangements marital!, 40 40 states collect health data bases will contain five data items to linkage! Some states and organizations are on the confidential use of this project to date has been the recommendation of data... 1998, all California State Department of Public health service organization What does ambulatory care Steven B. Cohen 9,! Outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers veteran..., Department of veteran 's Affairs ( 191 ), W. Michael Boyson M.H.A... The mother 's highest grade of schooling completed should be completed whenever there is a standardized, screening. Future projects may undertake to seek consensus among some of these elements and definitions being adopted in their program to... Vocabulary and classifications clear-cut listing of mutually exclusive encounter locations or definitions draw... Insurers, and the Committee will await the omb recommendations starting with the exception of unique identifier to provider... Must be refined and made available in standardized formats to data collectors or to... The first 12 elements, with the exception of unique identifier to each provider Agency for health care and! Care include the patient & # x27 ; s face sheet output of this item for inpatients ambulatory... Among other facilities felt that the Committee will await the omb recommendations record to be updated to include payment when... Be located on the Internet that could be used for these activities must refined... Home under care of organized home health service organization What does ambulatory care, there was clear-cut... Of Adolescent Medicine, Department of health data on inpatient hospital stays. sets... M.D., M.P.H Institute, NIH, Alfred S. Buck, M.D Ph.D. Additional evaluation and are...
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