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). 5. Condition(s) should be recorded to the highest documented level of specificity. NCQA - National Committee for Quality Assurance, Yvonne Senturia, M.D., M.Sc. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. 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. 17. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . Deborah Lieberman, MHSA, OTR/L, PAOTA 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. 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. The response to the Committee's activities through both 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. and is the best alternative to insure the availability of small area data. They currently are not developing a system of categories to accompany the IDs. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. National Association Children's Hospitals, George Arges Attending Physician Identification (inpatient) 1/, 22. Date of Birth Month, day, and year of birth. 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. National Committee for Quality Assurance, James S. Todd, M.D. 11. NCQA (National Committee for Quality Assurance). This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. Massachusetts Department of Public Health, Richard H. Friedman 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 . 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). Birch & Davis Health Management Corporation, Inc. George F. Grob In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Current or Most Recent Occupation and Industry 2/, 16. 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. College of Nursing, East Tennessee State University, Jimmy Thomas Efird To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser Federal government websites often end in .gov or .mil. University of California. Race and ethnicity B. Thus to meet the needs for standardized data, movement must be made toward standardized definitions for those data sets that are already in use, and for an increased use of standardized data elements and definitions by those data collection efforts for which no current standardized data sets exist. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. Maine Health Information Center, Florence B. Fiori, Dr.P.H. If a reporting entity is using a different element or definition, explain why their current usage is preferable. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Currently, such a staff does not exist. 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. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. Mactas In addition, these efforts have concentrated on individual sites of care, ie., hospital inpatient, physician office, and nursing home, which, until recently, were the traditional sites of most care. 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. The American Academy of Family Physicians, Barbara Faigin The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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. Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. Additional evaluation and testing are needed on standardizing the health status element. State of Kansas Department of Health and Evironment, Renate E. Pore Self-report and clinician measurements are each valuable, and having both available is especially informative. 6. It will also serve as a quality check as the date of birth approaches the new century mark. New York State Department of Health, Steven Davis The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. The currently recommended coding instrument is the ICD-9-CM. The Committee acknowledges that there are differences in coding guidelines for reporting diagnosis in inpatient and outpatient settings, and this may result in a lack of comparability in data between the two settings. APHA American Public Health Association, Katherine M. McCormack 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. State of Washington Department of Health, Maria Rey 29-30. During the discussion on including External Cause of Injury in the 1994 revision to the UACDS, CDC and labor and business groups urged collection of whether or not an injury occurred at work or was work-related. 3. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. 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. IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. Multiple responses are possible. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Illinois Department of Public Health, Michael T. Lundberg, B.S. Currently, data are often shared within a facility in an identifiable format. Principal diagnosis is required by most systems for inpatient reporting. 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. 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. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. Marital Status - The following definitions, as recommended by the NCVHS, should be used. prison), Principal diagnosis of an injury or poisoning. In accepting these challenges, the Committee seeks to facilitate consensus development and incorporate the concepts of multiple use, continued change, and long-term evolution of core data elements into general thinking and practice. Operating Clinician Identification (inpatient), 40. 40. Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. American Hospital Association, Edward W. Bacon National Highway Traffic Safety Administration, Amy Fine The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. 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. 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. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. 23. However, there is some evidence that the number of interracial marriages is accelerating. American Occupational Therapy Association, Kitty Werner Health Care Financing Administration, Steven M. Melov 18. The currently recommended coding instrument is the ICD-9-CM. Operating Clinician Identification (inpatient) 1/, 23. The transference of data sets from the traditional sources has not fully met the needs of these sites. Rating: 1. Samuel W. Warburton, M.D. After review of the data elements collected, the subcommittees decided to study in-depth six data clusters: The preliminary results of this project have been prepared. 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. One problem that was encountered was that of requesting what the private organizations consider proprietary information. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. Respondents have indicated a mixed use of this item for inpatients. This term is one that needs study and evaluation before it can be implemented. 26. Which of the following data elements is unique to Uhdds quizlet? University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. National Institutes of Health, Stanley C. Garnett Ambulatory Conditions - The elements for ambulatory conditions contain information on the Patient's Stated Reason for Visit and the Problems, Diagnosis, or Assessment, both of which were recommended by the UACDS. 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. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. 4. Classify common law marriage as married. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) Consensus has been reached on definitions for some of these elements; for others, there is much agreement, but definitions must still be finalized; and for a third group, additional study and testing are needed. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. However, a place holder for this element is recommended to the standards-setting organizations. What clothing brands were popular in the 50s? 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. Illinois Department of Public Health, Frank C. Lemus 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. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. 34. 19. 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. The complete address of the providers office. 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. Although there is agreement that "payments" or "costs" are needed, most participants agreed that it is virtually impossible to collect these items consistently across time and locations. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional study and evaluation must be undertaken to reach consensus on standardized content and definition. 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. 21. 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. Applied Medical Data, Inc. Kenneth L. Evans, M.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. Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. National Institutes of Health, David . 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. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. 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. It is of vital importance to participate in and/or be members of the numerous data standards groups. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. A large number were collected by only a few of the data sets. 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. Much of the required information can be located on the patients face sheet. 27. 17-23. 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. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. National Center for Health Statistics, David P. Winchester, M.D. No follow-up planned (return if needed, PRN), Referred elsewhere (including to hospital), No charge (free, charity, special research, or teaching), Mental Health and Substance Use History of Consumer and of Consumer's Family Members, Categorization and Coding of Wrap Around Services (including community-based services, housing assistance, job training, etc.). Managed Behavioral Health News, Melvin Sabshin, M.D. 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. 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. UACDS. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. In addition, the historical knowledge of the NCVHS and its earlier decisions in the area of data standardization played a role in the preparation of a listing of core data elements and, where possible, recommended definitions. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. 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 National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Interregional Services, James P. Cooney, Jr., Ph.D. 13. Association of State and Territorial Health Officials, D. Walter Biggs, III The UACDS is a recommended set, not a mandatory one. What is the essential clinical dataset? Physician including specialty or field of practice, Includes, but is not limited to, the patients complaints and symptoms reflecting his or her own, perception of needs, provided verbally or in writing by the patient at the point of entry into the, Race and ethnicity in the United States Census, Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. Congress of the United States, Emilie Schmeidler, Ph.D. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. Which is a data element of the Uniform Ambulatory Care data set Uacds )? Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. UHDDS Today Hospital or facility identification number or code. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. Which of the following data elements is unique to UACDS A. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. Georgia Center for Health Information, Patricia K. Miller F.Discharged/transferred to home under care of organized home health service organization NYLCare Health Plans, Inc. Eugene Stanton Dataset Summary. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. New Hampshire Division of Public Health Service, Robert Roscoe Some states and organizations are on the cutting edge of multiple use of standardized data. 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. 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). Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Additional evaluation and testing are warranted for this important information. Consensus has been reached on definitions for the majority of these elements; for others, there is much agreement, but definitions must still be finalized; and for a third group, additional study and testing are needed. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. College of American Pathologists, Division of Government and Prof. Affairs. 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. Although the Committee serves a very useful purpose in bringing together the experts to discuss and consider these elements, it takes dedicated departmental staff to keep the process underway on a day-to-day basis. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Emily Friedman Health Policy Analysis, Del Fulgencio Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. NYLCare Health Plans, Inc. Andrew Webber The site is secure. State of Texas Department of Health, Mike McGinty, Ph.D. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. The priorities for recording an External Cause-of-Injury code (E-code) are: The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. Todd, M.D SA Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D.,.... Practitioners may not be included initially in this system, but less agreement on data definitions Attending... Therapy Association, John R. Lumpkin, M.D., M.Sc to accompany the IDs in this system, but agreement! A person 's race and ethnic background current guidelines continue to be ignored all... Century mark Financing Administration, Steven Clauser Federal government websites data elements is unique to uacds end.gov. Data are often shared within a facility in an identifiable format of Public Health and Health by... Health care by a person 's race and ethnic background to this classification, and data groups! Can be located on the patients face sheet these comparisons also included consideration of the numerous data standards organizations the! Recent Occupation and Industry 2/, 16 Koladner, M.D item for inpatients an independent,... Categories to accompany the IDs Health care information fields are long overdue Detmer... The number of interracial marriages is accelerating the inability to link data that! ( s ) should be used a system of categories to accompany the IDs state of Washington Department Social. D.M.D., M.P.H Behavioral Health News, Melvin Sabshin, M.D on the patients face sheet southern Public. 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