data elements is unique to uacds

Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. Provide stable resources to the project to establish an interagency work group, with DHSS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. Recommendations and linkage with the current project will be discussed. A. Race and Ethnicity - The collection of race and ethnicity have been recommended by the UHDDS and the UACDS, and these elements have a required definition for Federal data collection in Office of Management and Budget (OMB) Directive 15. The Committee recommends the following actions specifically related to the core data elements: 3. 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. National Center for Health Statistics, Richard Rubin Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. Of these, approximately 70 percent provided information about their data elements. Operating Clinician Identification (inpatient), 40. 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. A second study is currently underway, one which will investigate core data elements in common use in data sets on persons with disability and/or persons receiving long term care. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional evaluation and testing must be undertaken to reach consensus on standardized content and definition. 1. 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) Circulate the report within the Department for review and constructive criticism. 38. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 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. Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS compare data for inpatients and ambulatory patients in the same or among other facilities. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell College of American Pathologists, Division of Government and Prof. Affairs. FACEP Department of Health and Human Services, Cheryl Beversdorf . 15. 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. 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. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. 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. Data quality is a perennial issue. This element refers to living arrangements only. Principal Diagnosis (inpatient) - As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. 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. 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). College of Nursing, East Tennessee State University, Jimmy Thomas Efird Which data is collected on Medicare and Medicaid patients? Medicare and many other payers adhere to these guidelines. 34. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. A large number were collected by only a few of the data sets. The Subcommittee determined that residential street address has the advantage of enabling researchers to aggregate the data to any level of geographic detail (block, census tract, ZIP code, county, etc.) 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. Standards groups should be consulted regarding setting criteria for recording of names. Permanente Medical Group Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.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. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. C.Child Massachusetts Department of Public Health, Richard H. Friedman Confidentiality of identifiable records is another critical issue. The Committee's intent is not to specify a data set for mandated external reporting; not every element may be needed in a specific collection effort, and these data elements do not represent all of the important data items that are collected in the field or needed for specific applications. 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. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. 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. Selma C. Kunitz, Ph.D. 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. Qualifier for Other Diagnoses (inpatient), 28. 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. 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. 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. Medical and Health Research Association, Gregg A. Pane, M.D. 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. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. 24. To retrieve electronic data B. 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. 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. USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. Principal diagnosis is required by most systems for inpatient reporting. The Committee recommends that the Department fund these activities on an ongoing basis. Presentations were received from state health departments, including California, Oklahoma, and New York; organizations such as the Joint Commission on the Accreditation of Healthcare Organizations; and individuals such as Dr. James Cooney, Associate Director, Georgia Center for Health Policy, who had participated in earlier Committee efforts to define uniform data sets. 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. Non-excision all debridement of stage three pressure ulcer of subcutaneous tissue of buttock. 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. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. State of New Jersey Department of Health, Dennis Duffy More emphasis on the confidential use of SSN is essential. HCFA has also provided information on its efforts to define a core data set for states and managed health care plans (McData), which is undergoing review at this time. 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. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. 22. Where can I watch the entire Dragon Ball series for free. 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. Interregional Services, James P. Cooney, Jr., Ph.D. This has resulted in inconsistent data found in many outpatient databases and has skewed patient outcome studies. HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. Standardized data sets can serve many purposes in the current and future health care arena. Connecticut Children's Medical Center, Geraldine Oliva State of Washington Department of Health, Maria Rey Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich The Committee has recognized that data confidentiality is a major concern in the collection of health data from an increasing number of sites, and the Committee has long been concerned with personal privacy and data confidentiality issues. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. 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). National Cancer Institute, NIH, Alfred S. Buck, M.D. Capture of the full four-digit year of birth is recommended 03. What clinical information is collected in the Uhdds? 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 Resources and Services Administration, Lorne A. Phillips, Ph.D. Date of Encounter (outpatient and physician services), 18. 32. 4. Center for Health Policy Studies, Carrie Dunkle, RN The data sets promulgated by the NCVHS have become de facto standards in their areas for data collection by Federal and state agencies, as well as public and private data abstracting organizations. 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. The HCFA Common Procedure Coding System (HCPCS), based on CPT-4, is required for physician (ambulatory and inpatient), hospital outpatient department, and free-standing ambulatory surgical facility bills; however, NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Kunitz and Associates, Inc. Laura B. Landrum 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. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. 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. Type of Encounter - This element is critical to the placement of an encounter of care within its correct location, i.e., hospital inpatient , outpatient, emergency department, observation, etc. Health Care Practitioner Identification (outpatient), 21. National Institute of Occupational Safety and Health, Stewart H. Streimer UACDS differs from UHDDS with data elements specific to ambulatory . 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. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. 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. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. Health Care Financing Administration, Steven M. Melov NCQA (National Committee for Quality Assurance). Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. 39. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. 33-35. Anonymous Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. University of Pennsylvania Medical Center, Steven Kappel A lack of footnote indicates that these elements are ready for implementation. To retrieve electronic data B. Currently there is little or no input from the public health field for several reasons. 19. Health Care Financing Administration. 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. 11. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. 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. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. Why such data sets are needed in the current and evolving health care arena; What multiple functions they might accomplish for a variety of different users; What data elements (including definitions, vocabularies and coding structures) they might contain; and. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. Children's Memorial Hospital, Ernest J. Sessa This item attempts to define what actually motivated the patient to seek care and has utility for analyzing the demand for health care services, evaluating quality of care and performing risk adjustment. The set is used to collect demographic and clinical data on nursing home residents that must be completed for every resident at the time of admission and during reassessment periods. 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. A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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. 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. every facility where ambulatory care is delivered. 17. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl These data items include birth name, date of birth, place of birth, gender, and mother's first name. 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. 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.

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