Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. UACDS differs from UHDDS with data elements specific to ambulatory . 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. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. 24. 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. Patient's Stated Reason for Visit or Chief Complaint (outpatient) - Includes the patient's stated reason at the time of the encounter for seeking attention or care. 20. A. Work on this topic is currently ongoing in the NCVHS Disability and Long-Term Care Statistics Subcommittee. 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. Disposition of Patient (inpatient) 1/, 40. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. 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. The description of the element indicates this present lack of agreement. Armed with the extensive listing of potential data elements culled from the Compendium, in September 1995, the NCVHS contacted approximately 2,000 individuals and organizations in the health care utilization and data fields to seek their input in identifying those basic elements most in need of collection and/or in need of uniform definitions (appendix B). Health Care Financial Management Association/ASC X12, Kenneth E. Roos, M.S., M.B.A. The site is secure. 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). Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). Each item that is recommended must be considered carefully. 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. They currently are not developing a system of categories to accompany the IDs. The University of Illinois at Chicago, Eunice Chee 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. There is already consensus among data collectors and users for a significant number of data elements, especially elements related to person descriptors and to selected information on inpatient and ambulatory encounters. Common data elements and areas for standardization will be considered as well as criteria for selection of data elements. Significant medical procedures performed. 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. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. Operative Report PREOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor POSTOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor OPERATION: Directions: Discussion Overview: Choose a specific commonly collected data set (UHDDS, CDC, NCDB, UACDS, OASIS, HEDIS, etc.) Of these, approximately 70 percent provided information about their data elements. New York State Office of Mental Health, James T. Howell, MD Health Care Financing Administration, Brenda Spillman American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. 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). In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. Mactas New York State Department of Health, Steven Davis A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. 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 project has brought together efforts from several state agencies, including education (for the school data), agriculture (the source of WIC data in some states), as well as health departments. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. ICD-10-PCS code for: 1. 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. NUBC (National Uniform Billing Committee), NUCC (National Uniform Claim Committee), and. In addition, the usefulness of both current/most recent occupation and industry as well as the addition of usual or longest held occupation and industry must be evaluated. It is possible that the description of functional status may entail more than a single measure, thus needing space for more than one measure and/or an additional element to document the scale used. In August 1994, the Department recognized the National Committee's unique history in promoting standardization of health information when it 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. If you continue to use this site we will assume that you are happy with it. In the future, the system will integrate non-HCFA subscribers. Uniform hospital discharge data set (UHDDS). He had visited a number of western European countries speaking with experts in health information infrastructure, and reported that several countries now have a national policy of support for the computerized patient record. 18. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards National Institutes of Health, Stanley C. Garnett National Institute of Occupational Safety and Health, Stewart H. Streimer 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. 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. 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. Georgia State University, Maria Redona Couper 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. On that same day NCVHS submitted to the DHHS Data Council its recommendations for standardizing 42 core health data elements, including demographic, socioeconomic, and health status information about a person and data specific to a person's encounter with the healthcare system on either an inpatient or outpatient basis. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. Where can the Uhdds data elements be found? 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. Selma C. Kunitz, Ph.D. The following list of data elements contains those elements selected for the first iteration of this process. 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. Living/Residential Arrangement - The following definitions are recommended by the NCVHS: Multiple responses to this item are possible. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. The Committee recommends that the Department fund these activities on an ongoing basis. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl All have significant value and could result in the collection of four separate data elements. 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 will do so by assigning a unique identifier to each provider. 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. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. 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. However, the activities envisioned by many participants go much farther than an advisory committee can handle. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. Uniform hospital discharge data set Functional Status - The functional status of a person is an increasingly important health measure that has been shown to be strongly related to medical care utilization rates. Social Security Administration, Andrew A. The definition has been expanded slightly from the OMB requirement: It is recommended that this item be self-reported, not based on visual judgment or surnames. Performance monitoring and outcomes research are two additional areas that are currently hampered by the inability to link data sets from various sources due to varying data elements and definitions. This item already is collected by most state health data organizations collecting hospital discharge information and offers the only readily available information on the fiscal dimensions of care and the relative costs of different types of care. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. 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. Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). 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. Gender As recommended by the UHDDS and the UACDS. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. A total of 31 responses were received. 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. What clothing brands were popular in the 50s? Health Resources and Service Admin. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. 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. Although the UHDDS has been in the field for two decades and its data items are widely used by government and private organizations, issues of quality and comparability remain. 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. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. 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. 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. Association of State and Territorial Health Officials, D. Walter Biggs, III Other data items are related to a specific episode of care and will be provided at each encounter. 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). Legal Services of Middle Tennessee, Leonard Bourget Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. 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. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. 1. Paul L. Grimaldi, Ph.D. ), particularly when used alone, and impediments (legal and otherwise) to its use. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. Connecticut Children's Medical Center, Geraldine Oliva University of California--San Francisco, Marlene M. Lugg Virginia Health Information, Charles MacKay Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. The Minimum Data Set for long term care (MDS) was published by the Department of Health & Human Services in 2013 and modified in 2016. 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. Paul Y. Ertel, M.D. Shortly after arrival in the ER, the patient's. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. Most organizations were supportive in wanting to 'get on board' with standardized data elements. IM System, David Newman, M.D. The Committee's 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. What does UACDS stand for? The currently recommended coding instrument is the ICD-9-CM. American Society of Ophthaimic Registered Nurses. Maine Health Care Finance Commission, Harriet Starr UHDDS Today Hospital or facility identification number or code. Years of schooling has been found to be highly predictive of health status and health care use. 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. 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. . Problem, Diagnosis or Assessment (outpatient). It is recommended that convergence of these guidelines be investigated. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. Where can I watch the entire Dragon Ball series for free. Current or Most Recent Occupation and Industry, 28. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self This element refers to living arrangements only. The UHDDS guidelines state all significant procedures are to be reported and a significant procedure is defined as one that is: Surgical in nature, or. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. It might not be feasible to expect the record to be updated to include payment data when it becomes available. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer 6. National Academy for State Health Policy, Marie Roberto, Dr.P.H. The number of standards-setting organizations is growing; however, all who addressed the Committee are actively seeking participation by a 'recognized' leader/group who can forge consensus for the health care information field. 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. Rating: 1. Additionally, includes optional data elements to describe the patients living arrangements and marital status. HBO and Company. The UACDS is a recommended set, not a mandatory one. C.Child ASTM Committee E-31, Clifford P. Binder 40B. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. If a reporting entity is using a different element or definition, explain why their current usage is preferable. Rural Health Advocacy Institute, Kevin Donnellan National Center for Health Statistics, Walter P. Bailey "Payers" are defined as public and private entities that have contract responsibility for health care payment. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. Ideally, one would also collect income to more fully define socioeconomic status. Congress of the United States, Emilie Schmeidler, Ph.D. 10. In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." UACDS and UHDDS have many similar data elements, which makes it easier to. 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. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. A lack of footnote indicates that the element is ready for implementation. 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. Which of the following data elements is unique to Uhdds quizlet? 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. Of 18 trade or professional associations contacted, only four submitted data sets. Workgroup for Electronic Data Interchange, Lucy Johns H.Left against medical advice or discontinued care. 1. jr pk hg ws qk bc qp wi Describe each data set element, who developed the data set, and compare the similarities and differences of each data set to the others for the following 3 data sets Uniform Hospital Discharge Data Set (UHDDS) for inpatients Uniform Ambulatory Care Data Set (UACDS) for outpatient or ambulatory patients Minimum Data Set (MDS) for long-term care. 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. Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. 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. Place holders will be set, and, in some cases data items and definitions decided on, before national and local public health agencies and organizations will be able to act. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . Those present at the November and December 1995 NCVHS regional meetings agreed that the establishment of a unique identifier is the most important core data item. Computer Network Architects, Inc. Barry Gordon 15. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. 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. 28-31. 01. National Center for Health Statistics, David P. Winchester, M.D. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. State of Florida Agency for Health Care Administration, Kathryn Huntley It is of vital importance to participate in and/or be members of the numerous data standards groups. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. The Committee encourages the Department and its partners to give high priority to conducting evaluation and testing on such elements and also seeks to alert organizations developing standards or data sets to leave place holders for their inclusion. To retrieve electronic data B. 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. 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) In addition to requesting a written response from these experts, they were invited to participate in one of two special meetings organized by the Committee to discuss the project and to seek input. We use cookies to ensure that we give you the best experience on our website. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. HRSA, Bureau of Primary Care, Mary Reister Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Providers, Insurers, and universities represented about 7 percent each. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Illinois Department of Public Health, Michael T. Lundberg, B.S. 26. In order to have as wide a participation at the meeting as possible, both East and West coast meetings were held in Oakland, CA, in early November, and in Washington, DC, in early December. 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. 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. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. Attending Physician Identification (inpatient), 22. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. Members of the Committee and DHHS staff participate when possible, however, the increasing numbers of groups and meetings is problematic from a staff and budget point of view. DCPC/NCCDPHP/CDC, Raymond C. Zastrow 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.) The information that this element provides on the causes of patients' injuries or adverse effects is considered essential for the development of intervention, prevention and control strategies. This element is currently collected on the HCFA 1500 form. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. NYLCare Health Plans, Inc. Eugene Stanton Who will have access to the database for research purposes, and to what data, has yet to be determined. 23. See Page 1. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. Standards groups should be consulted regarding setting criteria for recording of names. National Indian Council on Aging, Inc. Jacqueline R. Bennett National Association of Health Data Organizations. HHS, HCFA, Office of Managed Care, Gordon Bonnyman It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. College of American Pathologists, Division of Government and Prof. Affairs. ASTM (American Society for Testing and Materials ). The transference of data sets from the traditional sources has not fully met the needs of these sites. Kaiser Foundation Health Plan, Matthew McKearn These include the review and implementation of core data elements and definitions within departmental data collection activities; formation of public-private work groups to assist in promulgating data elements for which consensus has been reached or for undertaking additional study on critical elements for which there are no standardized definitions. 17-23. To retrieve electronic data B. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Self-Reported Health Status - There was much interest in documenting health status, one element that can precipitate the demand for health care and help determine the prognosis, although there was no consensus on how its definition should be standardized.
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