19. Multiple responses are possible. B.Spouse 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. Of these, approximately 70 percent provided information about their data elements. Functional assessment scales must also be age-appropriate. Dataset Summary. It will also serve as a quality check as the date of birth approaches the new century mark. Include the full name of the provider as well as the National Provider. These data items include birth name, date of birth, place of birth, gender, and mother's first name. Current or Most Recent Occupation and Industry, 28. The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. 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. 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. The Committee recommends that the HHS Data Council: 2. 28. Their continuing study is involved with more detailed data elements that relate specifically to the areas of mental heath, substance abuse, and long term care. However, a place holder for this element is recommended to the standards-setting organizations. The Committee recommends that the HCFA identifier be adopted when completed. Recommendations and linkage with the current project will be discussed. UACDS. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. It is planned that enumeration of Medicare providers will begin in calendar year 1996. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. What are the Root Operations? But time is short; decisions are being made by organizations now. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. 5. 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. 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. Definitions must be refined and made available in standardized formats to data collectors. The draft listing was again disseminated in early April 1996 (see appendix F) to the original mailing list and especially to those who had provided earlier assistance. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. No decisions have been made by the Department on any of these recommended revisions of either the UHDDS or the UACDS. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 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. C.Discharged/transferred to skilled nursing facility (SNF) Race and ethnicity B. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes The Committee recommends the following actions specifically related to the core data elements: 3. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. Interregional Services, James P. Cooney, Jr., Ph.D. Assistant Secretary for Planning and Evaluation, Room 415F American Society of Ophthaimic Registered Nurses. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. Health Care Financing Administration, Steven B. Cohen Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey What does UACDS stand for? Most organizations were supportive in wanting to 'get on board' with standardized data elements. 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). Don L. Zimmerman, Ph.D. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. 17-23. 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. What does ambulatory care include? ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. From the respondents, a total of 138 different data elements were obtained. A. American Medical Association, Herbert G. Traxler, Ph.D. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. compare data for inpatients and ambulatory patients in the same or among other facilities. The site is secure. 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. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. 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. ICD-9-CM Vol. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. Carries a procedural risk, or. 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). With the exception of the personal/unique identifier, they do not need to be collected at each encounter. American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. 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. The database will contain payer names, billing addresses and business information. 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. Catherine McCabe 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. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. 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. Facility Identification - The unique HCFA identifier as described above. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. 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. 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. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. What is Uacds? Health Care Practitioner Specialty 1/, 27. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. Self-report and clinician measurements are each valuable, and having both available is especially informative. MPH Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Response was significant and positive to the Committee's request to review a set of core data elements that were identified after a series of hearings and other information- gathering efforts were completed. 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. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell 9. (Currently approximately 40 states collect health data on inpatient hospital stays.) Federal government websites often end in .gov or .mil. Race and ethnicity 04a. Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. 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. The Committee encourages the development of one taxonomy and will monitor progress. Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. C.Child Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. American Medical Association, Zili Sloboda, Sc.D. During the October 1995 and March 1996 NCVHS meetings, Dr. Don Detmer, University of Virginia, updated the Committee on international progress in data standardization and computerized patient records. 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. . External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. American Psychiatric Association, Thomas C. Sawyer State of Texas Department of Health, Mike McGinty, Ph.D. Ideally, one would also collect income to more fully define socioeconomic status. 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). Years of schooling has been found to be highly predictive of health status and health care use. Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. Kunitz and Associates, Inc. Laura B. Landrum 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. The NCVHS notes that the Department of Veterans Affairs routinely collects this element, and thus approves the continued inclusion in this core list, pending a review of uses and users of this element. Additionally, a consensus must be reached on the unique personal identifier. 01. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser Operating Clinician identification 1/. 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. The Committee recommends that the HCFA identifier be adopted when completed. Without a universal unique identifier or a set of data items that can form a unique identifier, it will be impossible to link data across the myriad of healthcare locations and arrangements. Permanente Medical Group 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. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock 21. Applied Medical Data, Inc. Kenneth L. Evans, M.D. Health Insurance Association of America, John I. Gallin, M.D. An example of this could be NAHDO which could undertake to work with its members. Standard electronic formats are recommended to the extent that they have been developed. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. University System of West Virginia, Curtis O. Porter In August 1994, the Department 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. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). Medical and Health Research Association, Gregg A. Pane, M.D. "Payers" are defined as public and private entities that have contract responsibility for health care payment. 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. 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