Also in March, a consultant to the NCVHS updated the World Health Organization on the core data element activity and returned with input to the process. 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. The Committee recognizes that a person's social support system can be an important determinant of his or her health status, access to health care services, and use of services. 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. American Medical Association, Herbert G. Traxler, Ph.D. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Illinois Department of Public Aid, Amanda Attridge Henson D.Other (specify). However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. Medications Prescribed - Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code, dosage, strength, and total amount prescribed. Years of schooling has been found to be highly predictive of health status and health care use. Congress of the United States, Emilie Schmeidler, Ph.D. Applied Medical Data, Inc. Kenneth L. Evans, M.D. Uniform Ambulatory Care Data Set (UACDS). 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. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. 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. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self Gender - Male, Female. The National Provider Identifier and National Provider File (NPI/NPF), currently under development by the Health Care Financing Administration (HCFA) and intended for implementation in 1997, could and should meet this need, if all providers are included. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. Functional assessment scales must also be age-appropriate. ICD-10-PCS code for: 1. American Physical Therapy Association, Anthony J. National Center for Health Statistics, Richard Rubin As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. Standard electronic formats are recommended to the extent that they have been developed. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. At the very minimum, there need to be "place holders" provided to standards organizations to inform them that certain data elements are critical elements, even when the specific format of the items is currently undecided. American Association of Retired Persons, Peg Douglas White, M.P.H., Ph.D. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. 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). Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. Paul L. Grimaldi, Ph.D. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. In addition, the historical knowledge of the NCVHS and its earlier decisions in the area of data standardization played a role in the preparation of a listing of core data elements and, where possible, recommended definitions. Periodicity of assessment also is an issue. Of 18 trade or professional associations contacted, only four submitted data sets. Birch & Davis Health Management Corporation, Inc. George F. Grob St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. Primary Diagnosis (inpatient) - The diagnosis that is responsible for the majority of the care given to the patient or resources used in the care of the patient. Administration for Children and Families, Susan N. Postal National Association Children's Hospitals, George Arges 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. Physician including specialty or field of practice, Includes, but is not limited to, the patients complaints and symptoms reflecting his or her own, perception of needs, provided verbally or in writing by the patient at the point of entry into the, Race and ethnicity in the United States Census, Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. 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. 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. A commonly used measure is the person's rating of his or her own general health, as in the five-category classification, "excellent, very good, good, fair, or poor." HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. It will also serve as a quality check as the date of birth approaches the new century mark. The Committee acknowledges that there are differences in coding guidelines for reporting diagnosis in inpatient and outpatient settings, and this may result in a lack of comparability in data between the two settings. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. An example of this could be NAHDO which could undertake to work with its members. 36. HBO and Company. 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. It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. The currently recommended coding instrument is the ICD- 9-CM. The currently recommended coding instrument is the ICD-9-CM. 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 continuing expansion of types of payments and the combination of payments within groups is ever changing. In a number of instances, lists of data items were obtained, but without definitions. 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). Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Managed Behavioral Health News, Melvin Sabshin, M.D. 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. IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock A detailed report of these findings is in the process of publication by AHCPR, but findings have shown that even well-recognized standards are not consistently followed. Phillippine Nurses Association of America, Karen Grady The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan Used in the National Health Interview Survey and many other studies, this item has been shown to be predictive of morbidity, mortality, and future health care use, when collected in a general interview type of setting. APHA American Public Health Association, Katherine M. McCormack 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 currently recommended coding instrument is the ICD-9-CM. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. However, the activities envisioned by many participants go much farther than an advisory committee can handle. 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. Maine Health Care Finance Commission, Harriet Starr State of Texas Department of Health, Mike McGinty, Ph.D. Sex, age, and race of the patient. 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) 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. 13. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 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 those elements that the Committee recommends as being ready to standardize, request each of the data collection entities within the Department to review the set of data elements and to match data contents and definitions with similar items that they are currently collecting or plan to collect. What is Uacds? 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. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Significant medical procedures performed. Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. Interregional Services, James P. Cooney, Jr., Ph.D. They have influenced the claim forms on which Medicare and Medicaid data sets are based. 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. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. 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. This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. State of Florida Agency for Health Care Administration, Kathryn Huntley Anonymous Sex Male or female 04. The ICD-9-CM is the recommended coding convention. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. 22. 34. D'Angelo, B.S., M.S. A. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. 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. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. 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. Which of the following data elements is unique to UACDS? Common data elements and areas for standardization will be considered as well as criteria for selection of data elements. Massachusetts Department of Public Health, Richard H. Friedman 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. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. Illinois Department of Public Health, Michael T. Lundberg, B.S. The draft systems requirement definition was issued in January, 1995. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). To this end, the Committee has advised the Department on such matters as Federal-state relationships, nomenclatures and classification systems, core data sets, and access and confidentiality issues. Patient's Stated Reason for Visit or Chief Complaint (outpatient). Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Future projects may undertake to seek consensus among some of these items. Department of Agriculture, Theresa Wulbrecht Medicare and many other payers adhere to these guidelines. 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. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Core Health Data Elements Project 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. At the present time, standards- setting organizations should assign place holder(s) for this element. 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. 17-23. Birth weight of newborn is readily available in the medical record and has singular importance for risk-adjustment outcome studies and health policy development related to maternal and infant health. ANSI HISPP (Health Informatics Standards Planning Panel). A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. ASTM Committee E-31, Clifford P. Binder Carries a procedural risk, or. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. Assistant Secretary for Planning and Evaluation, Room 415F The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. Molly A. Anthony, Ph.D. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Medicare decided a PAYERID was needed because of the difficulty its contractors were having in transferring claims to other insurance companies, due to incomplete information or multiple names for payers. In the early 1990's, it formed an Ad Hoc Work Group on Confidentiality to study issues related to confidentiality, unique personal identifiers and data linkage across time and systems. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. 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. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Refer the core health data elements recommendations to the National Uniform Claim Committee for their consideration as they study the issue of uniform data elements for paper and electronic collection in Fall 1996. 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. A total of 31 responses were received. 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. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes Condition(s) should be recorded to the highest documented level of specificity. Operating Clinician Identification (inpatient), 40. 32. National Institute of Occupational Safety and Health, Stewart H. Streimer Patient's Expected Sources of Payment 1/. Type of Facility/Place of Encounter. However, recent testimony has led the Committee to investigate this issue further, in light of perceived inadequacies of the SSN (e.g., lack of a check digit, multiple SSN's, etc. What are the Root Operations? The usual living/residential arrangement of an individual is important for understanding the health status of the person as well as the person's follow-up needs when seen in a health care setting. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. These elements are unique to the UACDS. Other recommendations will be circulated for comment at a future time. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. Date of Encounter (outpatient and physician services), 18. 3. 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. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. HHS, HCFA, Office of Managed Care, Gordon Bonnyman Randall Spoeri, Ph.D. Compelling evidence presented by the Indian Health Service, states and nonprofit organizations demonstrates that effective intervention strategies can be implemented in response to available data on external causes of injury. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. 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. 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. Ambulatory Conditions - The elements for ambulatory conditions contain information on the Patient's Stated Reason for Visit and the Problems, Diagnosis, or Assessment, both of which were recommended by the UACDS. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. 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. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. Health Care Financing Administration, Brenda Spillman 23. Although there is agreement that "payments" or "costs" are needed, most participants agreed that it is virtually impossible to collect these items consistently across time and locations. It might not be feasible to expect the record to be updated to include payment data when it becomes available. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. Data sets received were assessed for their consistency with other data sets, particularly minimum data sets such as the UHDDS and the UACDS, the HCFA 1500 and the UB 92 data sets, and also with other current and future data sets under development by data standards organizations (ANSI). 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. 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. U.S. Department of Health and Human Services There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Whichever method is used should be designated. Health Care Financing Administration, Steven B. Cohen HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. 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. Georgia State University, Maria Redona Couper Federal government websites often end in .gov or .mil. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. Georgia Center for Health Information, Patricia K. Miller Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Social Security Administration, Andrew A. NYLCare Health Plans, Inc. Eugene Stanton HHS, Health Care Financing Administration, Kim Streit In some situations, it is possible that a free-form narrative will be collected in place of the codes, to be coded at a later point. Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. State of New Jersey Department of Health, Dennis Duffy Several major issues were raised that were broader than the discussions of specific data elements. Include Payment data when it becomes available comparisons also included consideration of the general availability reliability. 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