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. The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity. D.Discharged/transferred to an intermediate care facility (ICF) 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. Mactas 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). Health Resources and Services Administration, William E. Flynn, III Most organizations were supportive in wanting to 'get on board' with standardized data elements. Another problem is that, although the HHS Data Council has recently established a Health Data Standards Committee, until the past few months, there has been no central location within the Department for monitoring the activities of the data standards groups. 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. 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. FACEP A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. The complete address of the providers office. 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. Birch & Davis Health Management Corporation, Inc. George F. Grob Multiple responses are possible. 42. NCQA (National Committee for Quality Assurance). Include the full name of the provider as well as the National Provider. Who will have access to the database for research purposes, and to what data, has yet to be determined. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. 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. Marital Status - The following definitions, as recommended by the NCVHS, should be used. Classify common law marriage as married. In the future, the system will integrate non-HCFA subscribers. They currently are not developing a system of categories to accompany the IDs. 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. The NPI/NPF will provide a common means of uniquely identifying health care providers, including institutions, individuals, and group practices, both Medicare providers and those in other programs. Dataset Summary. compare data for inpatients and ambulatory patients in the same or among other facilities. They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. In these cases, it is possible that the data items, such as person characteristics, are part of a more basic file kept by the organization, and the information for that file was not included. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. and is the best alternative to insure the availability of small area data. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Managed Behavioral Health News, Melvin Sabshin, M.D. HHS, HCFA, Office of Managed Care, Gordon Bonnyman NYLCare Health Plans, Inc. Eugene Stanton 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. 15. IM System, David Newman, M.D. Oak Orchard Community Health Center, Geraldine Nicholson No EP studies. 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. 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. State of Washington Department of Health, Debra C. Hopkinson, RN, MS National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS Department of Health and Human Services, Cheryl Beversdorf To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. 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. 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.) With the exception of the personal/unique identifier, they do not need to be collected at each encounter. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. The draft systems requirement definition was issued in January, 1995. 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. Illinois Department of Public Health, Michael T. Lundberg, B.S. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Future projects may undertake to seek consensus among some of these items. ICD-9-CM Vol. Federal government websites often end in .gov or .mil. 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. 26. Condition(s) should be recorded to the highest documented level of specificity. Health Care Financing Administration, Emily Friedman American Public Health Association, Linda Vader, RN, CRNO Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. Much of the required information can be located on the patients face sheet. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Illinois Department of Public Aid, Amanda Attridge Henson These activities could take several forms. The Committee recommends that the Department fund these activities on an ongoing basis. 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. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Patient's Expected Sources of Payment, 12. Emily Friedman Health Policy Analysis, Del Fulgencio Additionally, includes optional data elements to describe the patients living arrangements and marital status. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. 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. With the assistance of the Center for Mental Health Services, SAMHSA, and a contractor, Webman Associates, a study was undertaken to identify and survey a representative sample of mental health, managed care, substance abuse, disabilities and long term care experts who would be willing to offer recommendations about the content of an ideal minimal data set for a health care record that is inclusive of the relevant information. It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. Personal Identification The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution. Each item that is recommended must be considered carefully. 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. National Center for Health Statistics. To identify the large number of organizations involved in various aspects of health data standards, staff at NCHS produced a report (see appendix H) describing the various groups by type of organization. Such a system would be helpful to the extent that it is feasible in the current highly dynamic market. Purpose: to identify data elements for a uniform minimum data set on ambulatory care CMS1500 (Claim form for Medicare/Medicaid Outpatient claims) is main vehicle used to collect UACDS data elements . Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. 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. What clothing brands were popular in the 50s? 2. 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. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. Which of the following data elements is unique to UACDS A. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. Years of schooling has been found to be highly predictive of health status and health care use. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. Applied Medical Data, Inc. Kenneth L. Evans, M.D. 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. 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. ICD-10-PCS code for: 1. 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 number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). 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. HBO and Company. It is of vital importance to participate in and/or be members of the numerous data standards groups. Office of the Assistant Secretary for Planning and Evaluation. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. American Psychiatric Association, Thomas C. Sawyer H.Left against medical advice or discontinued care. 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. The University of Illinois at Chicago, Eunice Chee Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. MPH 5. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. Medical and Health Research Association, Gregg A. Pane, M.D. 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 site is secure. 34. Aetna Health Plans, Sheila Horman National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. There is less agreement on data definitions, even for data items that have been in the field for years. Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. 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. 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." Kaiser Permanente, Medical Economics, Kathleen H. Fyffe 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. 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. Where can I watch the entire Dragon Ball series for free. National Association Children's Hospitals, George Arges 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. Of 18 trade or professional associations contacted, only four submitted data sets. Definitions must be refined and made available in standardized formats to data collectors. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. 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. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. Center for Mental Health Services, Corinne Kirchner, Ph.D. 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. offices, the location of the usual or principal place of practice should be given. Principal diagnosis is required by most systems for inpatient reporting. Other data items are related to a specific episode of care and will be provided at each encounter. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. 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. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. 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. The database will contain payer names, billing addresses and business information. California Department of Health Services, J. Henry Montes Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. B.Discharged/transferred to another short term general hospital for inpatient care 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. American Foundation for the Blind, Karen Kmetik But time is short; decisions are being made by organizations now. Center for Health Policy Studies, Rachael Block Carries a procedural risk, or. 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. More recently, the Department has been asked by the Vice President to play a leadership role, working with the Committee, in accelerating evolution of public and private health information systems toward more uniform, shared data standards. Michael L. Glickman National Institutes of Health, David . American Hospital Association, Edward W. Bacon Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. 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. 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. 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. To transmit electronic data C. To create a process for transmitting data to external users D. American Occupational Therapy Association, Kitty Werner The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 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. 7. National Institute on Drug Abuse, Cille Kennedy This element is currently collected on the HCFA 1500 form. Uniform Ambulatory Care Data Set. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. 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. 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. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. A. American Association of Retired Persons, Peg Douglas Common data elements and areas for standardization will be considered as well as criteria for selection of data elements. 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. 21. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. Department of Veterans Affairs, John A. Hornik, Ph.D. Interregional Services, James P. Cooney, Jr., Ph.D. 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. Congress of the United States, Vicki Hohner University of California, San Francisco, Jaclyn Packer Problems could arise from adding and modifying data items and definitions too frequently. 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. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. Don L. Zimmerman, Ph.D. Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS Type of Facility/Place of Encounter. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. 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. National Institutes of Health, Stanley C. Garnett Legal Services of Middle Tennessee, Leonard Bourget Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). National Center for Health Statistics, Barbara D. Matula Years of Schooling - Highest grade of schooling completed by the enrollee/patient. 29. What is the essential clinical dataset? Foundation for Health Care Quality, Terry Rudd It also includes other data elements such as Place of encounter to specify locations, reason for encounter that outlines the patient complaints and symptoms reflecting their own perceptions of needs, and diagnostic service that give a description of all types of service. 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. Before sharing sensitive information, make sure youre on a federal government site. American Medical Association, LaVerne D. Knezek, Ph.D. 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. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. At the present time, standards- setting organizations should assign place holder(s) for this element. The UACDS is a recommended set, not a mandatory one. 35. 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 major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. Health Care Financing Administration, Christine Rice Information is collected by a wide range of users and in a myriad of different formats. To UACDS a not part of the personal/unique identifier, they do need! 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