Illinois Department of Public Health, Frank C. Lemus The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. Current or Most Recent Occupation and Industry, 28. University of California, San Francisco, Jaclyn Packer The database will contain payer names, billing addresses and business information. 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. UACDS. 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. But time is short; decisions are being made by organizations now. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. 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) Columbia/HCA HealthCare Corporation, John Quinn The NCVHS recommends the use of Social Security Number with a check item such as date of birth, while at the same time undertaking the study and evaluation needed to confirm this use or the recommendation of another identifier. A total of 31 responses were received. Throughout the meetings it became apparent that many standards-setting groups are moving ahead without broader input, for example, from those in the public health and epidemiology fields. 14. This term is one that needs study and evaluation before it can be implemented. Providers, Insurers, and universities represented about 7 percent each. 31. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? Health Care Financing Administration, Steven M. Melov 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. National Institute of Occupational Safety and Health, Stewart H. Streimer 19. NUBC (National Uniform Billing Committee), NUCC (National Uniform Claim Committee), and. State of Florida Agency for Health Care Administration, Kathryn Huntley Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). Circulate the report within the Department for review and constructive criticism. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. The set includes reasons for the encounter, living arrangements, and marital status. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. A. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). The type of data collected in each different facility's patient health records is established by required standards or regulations. 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). Center for Health Policy Studies, Carrie Dunkle, RN Michael L. Glickman Participation in the system will be voluntary for non-HCFA providers at first. Provider Location or Address of Encounter (outpatient), 22. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. The Committee recommends that the HCFA identifier be adopted when completed. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. 3. Ronald Carlson Marital Status - The following definitions, as recommended by the NCVHS, should be used. 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. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. 5. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka Uniform Ambulatory Care Data Set (UACDS). Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. 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. A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. 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. Center for Mental Health Services, Corinne Kirchner, Ph.D. The MEDSTAT Group, Joel Diringer, JD. 4. Indian Health Service, Robert Davis Georgia State University, Maria Redona Couper In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. Recommendations and linkage with the current project will be discussed. State of Texas Department of Health, Mike McGinty, Ph.D. National Center for Health Statistics, Barbara D. Matula 39. Dave Baldridge Which of the following data elements is unique to UACDS A. Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self Race and ethnicity B. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. 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. Office of the Assistant Secretary for Planning and Evaluation. Oak Orchard Community Health Center, Geraldine Nicholson Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. 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. Definitions must be refined and made available in standardized formats to data collectors. Capture of the full four-digit year of birth is recommended 03. Health Resources and Services Administration, William E. Flynn, III UACDS. American Physical Therapy Association, Anthony J. Consensus building on data elements and definitions was, as always, a complex issue. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. 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); ANSI (American National Standards Institute). Shortly after arrival in the ER, the patient's. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND 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. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Maine Health Care Finance Commission, Harriet Starr Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. Which of the following data elements is unique to UACDS A. National Academy for State Health Policy, Marie Roberto, Dr.P.H. 1. 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. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser It is anticipated that these elements will be collected on a one-time basis or updated on an annual 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. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or What clothing brands were popular in the 50s? However, there is some evidence that the number of interracial marriages is accelerating. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. Bureau of Vital Records and Health Statistics. 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. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Where can the Uhdds data elements be found? The Committee encourages the development of one taxonomy and will monitor progress. 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. New York State Office of Mental Health, James T. Howell, MD 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. 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. Additionally, a consensus must be reached on the unique personal identifier. Who will have access to the database for research purposes, and to what data, has yet to be determined. The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Standards groups should be consulted regarding setting criteria for recording of names. The continuing expansion of types of payments and the combination of payments within groups is ever changing. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer With relatives other than spouse, children, or parents, Residence where health, disability, or aging related services or supervision are available, Other residential setting where no services are provided, Other institutional setting (e.g. 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) 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) Health Care Financing Administration, Christine Rice 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. Operating Clinician identification 1/. Currently, such a staff does not exist. A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. 4. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. Department of Veteran's Affairs (19), Lora Kraus 29-30. 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. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. Anonymous 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. As recommended by the UACDS, address should be in sufficient detail (street name and number, city or town, county, State, and Zip Code) to allow for the computation of county and metropolitan statistical area. American Occupational Therapy Association, Kitty Werner Additionally the move in the health care payment system to managed care has increased the need to be able to link data sets and individual records across time, facility, and broader geographic locations. Expected insurance payer number or code. The Committee works closely with the National Center for Health Statistics, the Agency for Health Care Policy and Research, and the Health Care Financing Administration (HCFA). 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. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. To transmit electronic data C. To create a process for transmitting data to external users D. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. Include the full name of the provider as well as the National Provider. 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. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. In a nutshell, the ECD defines the data elements that are essential to be documented for a patient within the EHR so the care team may provide quality care. If the HCFA system does not have separate identification numbers for parts of a hospital (i.e., Emergency Department, Outpatient Department), an additional element (such as element 13) will need to be collected along with the facility ID to differentiate these settings. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. New Hampshire Division of Public Health Service, Robert Roscoe 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. In the future, the system will integrate non-HCFA subscribers. 16. To retrieve electronic data B. American Hospital Association, Edward W. Bacon Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. 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. 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. Connecticut Children's Medical Center, Geraldine Oliva American Psychiatric Association, Thomas C. Sawyer Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. A person currently married. More emphasis on the confidential use of SSN is essential. Previous experience indicates that at least some, if not many, of these data items have differing definitions. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. 12. If you continue to use this site we will assume that you are happy with it. Information on all patient problems and diagnoses requiring attention at the encounter are needed to assess the quality of care delivered, to determine what types of health problems are being seen and treated in the different types of ambulatory care facilities, and for assessing the appropriateness of the setting used to perform the services. 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. The UACDS has never been officially promulgated by the Department, but a 1989 revision by the NCVHS and an Interagency Task Force has been widely circulated, as has a further refinement by the NCVHS in 1994. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA To retrieve electronic data B. National Highway Traffic Safety Administration, Amy Fine Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment.
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