Social Security Administration, Andrew A. Foundation for Health Care Quality, Terry Rudd The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. 29-30. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. 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). However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. Respondents have indicated a mixed use of this item for inpatients. 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. Centers for Disease Control and Prevention. The set includes reasons for the encounter, living arrangements, and marital status. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. Gender - Male, Female. National Indian Council on Aging, Inc. Jacqueline R. Bennett Race and ethnicity B. American Nurses Association, Larry W. Miller American Health Information Management Association, Louis I. Freedman Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. Georgia Center for Health Information, Patricia K. Miller American Society of Ophthaimic Registered Nurses. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). DCPC/NCCDPHP/CDC, Raymond C. Zastrow College of American Pathologists, Division of Government and Prof. Affairs. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. 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. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. National Institutes of Health, Stanley C. Garnett As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? 1. Virginia Health Information, Charles MacKay Race and ethnicity B. Health Level 7 Ernst & Young LLP, Jerri Regan What is the essential clinical dataset? USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. If you continue to use this site we will assume that you are happy with it. Applied Medical Data, Inc. Kenneth L. Evans, M.D. 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. Self-report and clinician measurements are each valuable, and having both available is especially informative. 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. 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. UHDDS Today Hospital or facility identification number or code. 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. Health Resources and Services Administration, William E. Flynn, III Each encounter generates a date of service that can be used to link encounters for the same patient over time. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. Maine Health Care Finance Commission, Harriet Starr University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. The currently recommended coding instrument is the ICD- 9-CM. A person who has never been married or whose only marriages have been annulled. Marital status is discussed in element 6. The Committee recognizes that a person's social support system can be an important determinant of his or her health status, access to health care services, and use of services. But time is short; decisions are being made by organizations now. Congress of the United States, Vicki Hohner The University of Illinois at Chicago, Eunice Chee St. Peter's Community Hospital, Ron Horner, Ph.D. Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN What clinical information is collected in the Uhdds? * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. ), particularly when used alone, and impediments (legal and otherwise) to its use. Race and ethnicity 04a. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. 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. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. The instruction clarifies that only what is known to the highest level of specificity should be reported. A. What clothing brands were popular in the 50s? 9. 11. Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. New York State presented testimony that indicated that the last four digits of the SSN combined with the birth date were capable of linking data to a very high degree of probability. Definitions must be refined and made available in standardized formats to data collectors. Assistant Secretary for Planning and Evaluation, Room 415F Department of Health and Human Services, Cheryl Beversdorf In a nutshell, the ECD defines the data elements that are essential to be documented for a patient within the EHR so the care team may provide quality care. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. 37. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. 1. The report provides important background information on coordinators and promoters of standards development; lead standards-development organizations; organizations developing performance measures indicators; departmental organizations; international organizations; and others. It is planned that enumeration of Medicare providers will begin in calendar year 1996. 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. 40B. The UACDS is a recommended set, not a mandatory one. One problem that was encountered was that of requesting what the private organizations consider proprietary information. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Where can the Uhdds data elements be found? 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. An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital. The currently recommended coding instrument is the ICD-9-CM. The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. In 1989, NCVHS approved the UACDS, recommending its use in. National Cancer Institute, NIH, Alfred S. Buck, M.D. 200 Independence Avenue, SW Procedures and Services (outpatient) - As recommended by the UACDS, describe all diagnostic procedures and services of any type including history, physical examination, laboratory, x-ray or radiograph, and others that are performed pertinent to the patient's reasons for the encounter; all therapeutic services performed at the time of the encounter; and all preventive services and procedures performed at the time of the encounter. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. Association of Maternal and Child Health Programs, Karl S. Finison 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. California Department of Health Services, J. Henry Montes Of 18 trade or professional associations contacted, only four submitted data sets. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. 4. 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). 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 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. Office of Statewide Health Planning and Development. 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. 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. Phillippine Nurses Association of America, Karen Grady 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. Facility Identification - The unique HCFA identifier as described above. National Center for Health Statistics, Richard Rubin 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. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. National Organization of urse Practitioner Faculties, Peter M. Wheeler Georgia State University, Maria Redona Couper 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 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. Favorable input has been received from a wide range of experts, and these elements should be compellingly useful both to states and to provider organizations. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. 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 elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. Additional evaluation and testing are warranted for this important information. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. Core Health Data Elements Project Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Medical and Health Research Association, Gregg A. Pane, M.D. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. 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. It is of vital importance to participate in and/or be members of the numerous data standards groups. An example of this could be NAHDO which could undertake to work with its members. Workgroup for Electronic Data Interchange, Lucy Johns 41. Problems could arise from adding and modifying data items and definitions too frequently. A. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. Maine Health Information Center, Florence B. Fiori, Dr.P.H. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. Course Hero is not sponsored or endorsed by any college or university. National Center for Health Statistics, David P. Winchester, M.D. 17-23. James Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the addition of a single data item. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. (9 days ago) What does uacds mean or stand for?UACDS means Uniform Ambulatory Care Data Set. 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. 34. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. Include the full name of the provider as well as the National Provider. 12. Paul L. Grimaldi, Ph.D. The Committee recognizes the need for uniform, comparable standards across geographic areas, populations, systems, institutions and sites of care to maximize the effectiveness of health promotion and care and minimize the burden on those responsible for generating the data. I need the ICD-10-PCS codes 2. These activities could take several forms. The database will contain payer names, billing addresses and business information. Operating Clinician Identification (inpatient), 40. New Hampshire Division of Public Health Service, Robert Roscoe Office of Inspector General. Additionally, too frequent modification of items or definitions will cause confusion, overlapping data definitions in a single data year, and add to the burden of the facility or organization. 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. 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. Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. 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. In the future, the system will integrate non-HCFA subscribers. A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. Uniform Ambulatory Care Data Set. C.Discharged/transferred to skilled nursing facility (SNF) 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. 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. 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. Alfred S. 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