Support implementation and testing activities for those data elements for which agreement on definitions has been reached and those for which minimal additional work is needed on definitional agreement. Review state-of-the-art of widely-used core data sets in the United States and other countries (including coding and formatting features that allow for flexibility); Obtain input, through hearings and other means, from the diverse parties who will report and use standardized data sets; Interact closely with recognized standards-setting groups; and. New York, using the last 4 digits of the Social Security Number, with other characteristics (such as date of birth), indicated a match rate exceeding 99 percent. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC . They have influenced the claim forms on which Medicare and Medicaid data sets are based. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. Kunitz and Associates, Inc. Laura B. Landrum Which of the following data elements is unique to UACDS? 12. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. The Committee's efforts, first in the area of inpatient hospital data (the Uniform Hospital Discharge Data Set or UHDDS) and later in the area of ambulatory care (the Uniform Ambulatory Care Data Set or UACDS) have moved the country in the direction of achieving comparability in the health data collected by federal agencies, states, localities and the private sector, as well as in the international community. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. For example, the State of California, in testimony to the NCVHS, described its efforts in improving health and health care delivery by linking data collected through medical facilities, school-based health and educational data bases, as well as need-based data bases such as eligibility listings for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) or reduced school-lunch programs. Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. American Medical Association, Mark Epstein, Sc.D. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. Managed Behavioral Health News, Melvin Sabshin, M.D. 13. In the future, the system will integrate non-HCFA subscribers. 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. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. H.Left against medical advice or discontinued care. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. Elliot M. Stone, M.V.C. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. American Medical Association, Zili Sloboda, Sc.D. 20. A lack of footnote indicates that these elements are ready for implementation. The Committee's efforts, first in the area of inpatient hospital data (the Uniform Hospital Discharge Data Set or UHDDS) and later in the area of ambulatory care (the Uniform Ambulatory Care Data Set or UACDS) have moved the country in the direction of achieving comparability in the health data collected by federal agencies, states, localities and the private sector, as well as in the international community. Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. Other recommendations will be circulated for comment at a future time. A lack of footnote indicates that the element is ready for implementation. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. Association of State and Territorial Health Officials, D. Walter Biggs, III Also, although different data sets may include the same data element, in most cases it was not possible to verify that the data collection instructions and definitions were the same. The description of the element indicates this present lack of agreement. The elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter. 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. 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. Participation is voluntary, and HCFA, which is funding its development, has been working to get consensus about the kind of system that would be useful. Ronald Carlson USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. Patient's Expected Sources of Payment 1/. Confidentiality of identifiable records is another critical issue. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. See Page 1. Michael L. Glickman The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. 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. Standard electronic formats are recommended to the extent that they have been developed. 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. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). In recent years, the focus of health care has been shifting to hospital outpatient and other outpatient care, including clinic, hospice and home care, sites for which standardized data collection had not been developed. B.Discharged/transferred to another short term general hospital for inpatient care What does UACDS stand for? Center for Health Policy Studies, Carrie Dunkle, RN Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. Maine Health Information Center, Florence B. Fiori, Dr.P.H. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. 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. With the assistance of the Center for Mental Health Services, SAMHSA, and a contractor, Webman Associates, a study was undertaken to identify and survey a representative sample of mental health, managed care, substance abuse, disabilities and long term care experts who would be willing to offer recommendations about the content of an ideal minimal data set for a health care record that is inclusive of the relevant information. Operating Clinician identification 1/. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. The personal/unique identifier is the element that is the most critical element to be collected uniformly. American Health Information Management Association, Louis I. Freedman It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. Consensus has been reached on definitions for the majority 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. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. C.Child 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. 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. Marital Status - The following definitions, as recommended by the NCVHS, should be used. White, M.P.H., Ph.D. C.Discharged/transferred to skilled nursing facility (SNF) To retrieve electronic data B. Vermont Health Care Authority, Michael G. Kassis University of California, San Francisco, Jaclyn Packer Disposition of Patient (inpatient) - As recommended by the UB 92 and as an expansion of the 1992-93 UHDDS data element: A.Discharged to home or self care (routine discharge) Centers for Disease Control and Prevention. It remains unclear whether the modest health gains seen in low-income and racial/ethnic minority populations in the last thirty years will continue, considering the changes in the U.S. health care system. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. Alexis A. Wilson 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. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. 42. 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. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. This group, or a separate group, could also be the focus for evaluating additions to the list of core data elements and for setting up methods for testing and promulgating the final products. Some third party payers, however, have ignored the guidelines and required facilities and health care practitioners to report a diagnosis that justifies the performance of services being provided. 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. Larry Deutsch, M.D., M.P.H. This effort, described below, is the culmination of input from the historical knowledge and work of the Committee, including the uniform basic data sets already developed; and information provided in meetings, hearings, and through correspondence with Federal, state and local health agencies, private organizations, universities, etc. Additionally, includes optional data elements to describe the patients living arrangements and marital status. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. Children's Memorial Hospital, Ernest J. Sessa Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital. 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. Health Care Financing Administration, Emily Friedman Centers for Disease Control and Prevention, Lynn E. Jensen, Ph.D. Computer Network Architects, Inc. Barry Gordon The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. Type of Facility/Place of Encounter 1/, 19. Items shown below with an asterisk (*) indicate that this type of information can be obtained from linking the NPI with the National Provider File and may not need separate collection. The major objectives of this project include the production of a report assessing existing data for care provided to persons with disabilities in institutional and community long term care settings, as well as in rehabilitation. Where can the Uhdds data elements be found? Illinois Department of Public Health, Frank C. Lemus National Institute of Occupational Safety and Health, Stewart H. Streimer G.Discharged/transferred to home under care of a Home IV provider Other data items are related to a specific episode of care and will be provided at each encounter. Include the full name of the provider as well as the National Provider. An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. 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). 40B. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. After review of the data elements collected, the subcommittees decided to study in-depth six data clusters: The preliminary results of this project have been prepared. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. A number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). HHS, Health Care Financing Administration, Kim Streit The set includes reasons for the encounter, living arrangements, and marital status. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. Procedures and Services (outpatient) - As recommended by the UACDS, describe all diagnostic procedures and services of any type including history, physical examination, laboratory, x-ray or radiograph, and others that are performed pertinent to the patient's reasons for the encounter; all therapeutic services performed at the time of the encounter; and all preventive services and procedures performed at the time of the encounter. 1. Deborah Lieberman, MHSA, OTR/L, PAOTA These data assist in the examination of disparities in stage of illness, care, and outcome, some of which have been documented in the past among racial and ethnic groups. Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. Workgroup for Electronic Data Interchange, Lucy Johns To retrieve electronic data B. FACEP 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. 4. At the October 1995 meeting of the NCVHS, a session was held at which the Department of Veterans Affairs, the Georgia State Department of Health, and others, demonstrated their institutions' integrated financial, clinical, consumer, and public health information systems that are currently in place or being tested. A series of matrices were prepared that arrayed individual data elements in use or proposed for use by different organizations with the type of organization. American Psychiatric Association, Thomas C. Sawyer Current or Most Recent Occupation and Industry 2/, 16. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. 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. Georgia State University, Maria Redona Couper Health Care Financing Administration, Steven B. Cohen D.Discharged/transferred to an intermediate care facility (ICF) Of 18 trade or professional associations contacted, only four submitted data sets. National Institutes of Health, David . American Medical Association, LaVerne D. Knezek, Ph.D. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. HHS, HCFA, Office of Managed Care, Gordon Bonnyman Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. It will also serve as a quality check as the date of birth approaches the new century mark. 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.
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