5. Computer Network Architects, Inc. Barry Gordon Randall Spoeri, Ph.D. HHS, Health Care Financing Administration, Kim Streit Race and ethnicity B. 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman It became obvious that staff dedicated to participating in and monitoring the activities of these organizations is crucial if all relevant voices (including public health and epidemiology) are to be heard. Interregional Services, James P. Cooney, Jr., Ph.D. The .gov means its official. Anonymous Virginia Health Information, Charles MacKay 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. 31. The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or At present, there is no widely recognized instrument for measuring the functional status of children. 12. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. 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. Patient's Expected Sources of Payment 1/. In addition to documenting whether the patient was discharged alive or died during the hospitalization, the patient disposition is an indicator of the patient's health status at the time of discharge and need for additional services. BlueCross BlueShield of Minnesota. New York State Office of Mental Health, James T. Howell, MD Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers. 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. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). Centers for Disease Control and Prevention. The Committee encourages the development of one taxonomy and will monitor progress. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution Birch & Davis Health Management Corporation, Inc. George F. Grob 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. 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. 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. As recommended by the UHDDS and the UACDS. Just trying to obtain data from some large organizations was quite difficult; responses were not received in a timely fashion, and when received, the data layouts often were computerized lists rather than lists of data items with their definitions. 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. Participation in the system will be voluntary for non-HCFA providers at first. 29. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. A lack of footnote indicates that the element is ready for implementation. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. Oak Orchard Community Health Center, Geraldine Nicholson The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. 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. No follow-up planned (return if needed, PRN), Referred elsewhere (including to hospital), No charge (free, charity, special research, or teaching), Mental Health and Substance Use History of Consumer and of Consumer's Family Members, Categorization and Coding of Wrap Around Services (including community-based services, housing assistance, job training, etc.). If a reporting entity is using a different element or definition, explain why their current usage is preferable. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. The currently recommended coding instrument is the ICD- 9-CM. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. Patient's Stated Reason for Visit or Chief Complaint (outpatient). Type of Facility/Place of Encounter 1/, 19. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. 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. The National Committee is well aware of the numerous efforts currently underway in both the public and private sectors to standardize health data, especially the progress made during the past 10-15 years in developing uniform data sets (Uniform Hospital Discharge Data Set and the Uniform Ambulatory Care Data Set) as well as common claim forms (Uniform Bill 82 and its successor UB 92 and HCFA 1500). Standards groups should be consulted regarding setting criteria for recording of names. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. The State of California has tested the use of a series of data items that are readily known by individuals and which can be combined to link data. 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. Currently, such a staff does not exist. NCQA (National Committee for Quality Assurance). Other Procedures (inpatient) - All other procedures that meet the criteria described in element 33. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. offices, the location of the usual or principal place of practice should be given. 42. Principal Procedure (inpatient)- As recommended by the UHDDS, the principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. Non-excision all debridement of stage three pressure ulcer of subcutaneous tissue of buttock. 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. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. In addition, a number of elements for which consensus is close, must be field tested to confirm their definitions and collectibility. Support the NCVHS in continuing its work in this area, especially using its expertise to discuss research issues, to assist in consensus building, and to participate with the Data Council in the implementation of the core health data element project recommendations. 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. D.Discharged/transferred to an intermediate care facility (ICF) Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. Place holders will be set, and, in some cases data items and definitions decided on, before national and local public health agencies and organizations will be able to act. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. 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. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. UHDDS Today Hospital or facility identification number or code. Connecticut Children's Medical Center, Geraldine Oliva However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Work on this topic is currently ongoing in the NCVHS Disability and Long-Term Care Statistics Subcommittee. Consensus has been reached on definitions for some of these elements; for others, there is much agreement, but definitions must still be finalized; and for a third group, additional study and testing are needed. Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Department of Veterans Affairs, John A. Hornik, Ph.D. Kunitz and Associates, Inc. Laura B. Landrum Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. Department of Public Health, Dan Rode 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. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. Attending Physician Identification (inpatient) - The unique national identification number assigned to the clinician of record at discharge who is responsible for the discharge summary, as recommended by the 1992 UHDDS. The Committee recognizes that this is an iterative process and has included in these recommendations several elements that have been proposed for standardization, even though no consensus currently exists concerning appropriate or feasible definitions. However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. With the exception of the personal/unique identifier, they do not need to be collected at each encounter. National Institute on Drug Abuse, Cille Kennedy Workgroup for Electronic Data Interchange, Lucy Johns This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. Assistant Secretary for Planning and Evaluation, Room 415F 40B. 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. 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). North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. Health Resources & Services Administration, Office of Policy Coordination, Nancy Moss, Ph.D. What clothing brands were popular in the 50s? Washington, D.C. 20201, U.S. Department of Health and Human Services, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Collaborations, Committees, and Advisory Groups, Physician-Focused Payment Model Technical Advisory Committee (PTAC), OS-Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, Core Health Data Elements: Report of the National Committee on Vital and Health Statistics. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Shortly after arrival in the ER, the patient's. Colorado Hospital Association, Nancy Breen, Ph.D. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Department of Health and Human Services, Cheryl Beversdorf What is Uacds? Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. Describe each data set element, who developed the data set, and compare the similarities and differences of each data set to the others for the following 3 data sets: Hi there, would you like us to [] Recommendations and linkage with the current project will be discussed. Thus to meet the needs for standardized data, movement must be made toward standardized definitions for those data sets that are already in use, and for an increased use of standardized data elements and definitions by those data collection efforts for which no current standardized data sets exist. Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. 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. 20. 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. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Current or Most Recent Occupation and Industry - This data item is very useful to track occupational diseases as well as to better define socioeconomic status. Health Care Financing Administration, James Tierney Provide stable resources to the project to establish an interdepartmental work group, with DHHS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. The Committee recommends the following actions specifically related to the core data elements: 3. Operative Report PREOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor POSTOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor OPERATION: Directions: Discussion Overview: Choose a specific commonly collected data set (UHDDS, CDC, NCDB, UACDS, OASIS, HEDIS, etc.) USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. See Page 1. Particular scales are more appropriate for measuring different functions or disabilities and should be selected on the basis of the needs of the patient population (such as, use of social functioning scales for those with mental disorders and substance abuse). Health Insurance Association of America, John I. Gallin, M.D. Health Resources and Services Administration, William E. Flynn, III Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. Uniform Ambulatory Care Data Set. Illinois Department of Public Aid, Amanda Attridge Henson California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. "Payers" are defined as public and private entities that have contract responsibility for health care payment. Columbia/HCA HealthCare Corporation, John Quinn 8. National Institute of Occupational Safety and Health, Stewart H. Streimer More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. Paul Y. Ertel, M.D. Operating Clinician Identification (inpatient), 40. and is the best alternative to insure the availability of small area data. American Medical Association, LaVerne D. Knezek, Ph.D. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. The currently recommended coding instrument is the ICD-9-CM. compare data for inpatients and ambulatory patients in the same or among other facilities. To retrieve electronic data B. Four digits are recommended for the discharge year. UNIFORM AMBULATORY CARE DATA SET. Some states and organizations are on the cutting edge of multiple use of standardized data. To this end, the Committee recommends that the Data Council: 3. Federal government websites often end in .gov or .mil. More emphasis on the confidential use of SSN is essential. 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