To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. 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. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. At present, there is no widely recognized instrument for measuring the functional status of children. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. University System of West Virginia, Curtis O. Porter 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. 28-31. 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. Paul Y. Ertel, M.D. It remains unclear whether the modest health gains seen in low-income and racial/ethnic minority populations in the last thirty years will continue, considering the changes in the U.S. health care system. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. 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. 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. every facility where ambulatory care is delivered. Health Resources & Services Administration, Office of Policy Coordination, Nancy Moss, Ph.D. 01. Uniform Ambulatory Care Data Set. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. 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. Current or Most Recent Occupation and Industry - This data item is very useful to track occupational diseases as well as to better define socioeconomic status. 24. National Center for Health Statistics, Walter P. Bailey Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. B.Spouse Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. All have significant value and could result in the collection of four separate data elements. What is the essential clinical dataset? There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. More emphasis on the confidential use of SSN is essential. Who will have access to the database for research purposes, and to what data, has yet to be determined. 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 Association Children's Hospitals, George Arges 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. Office of Inspector General. 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. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. 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. The instruction clarifies that only what is known to the highest level of specificity should be reported. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. 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. The following list of data elements contains those elements selected for the first iteration of this process. National Center for Health Statistics. There is less agreement on data definitions, even for data items that have been in the field for years. The database will contain payer names, billing addresses and business information. A. With the use of UHDDS-defined data, for example, state and private abstracting systems have been providing comparable state and local data for health planners for many years. 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. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. Office of Statewide Health Planning and Development. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. As a result of the process followed in the conduct of this project and based on careful analysis by its members, the Committee has reached the following conclusions: Because they recognize the significance of this project, respondents also recommended a number of additional items that they would like evaluated and possibly included in a core set of standardized data elements. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. 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. 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 . It will also serve as a quality check as the date of birth approaches the new century mark. A person who has never been married or whose only marriages have been annulled. Health Care Practitioner Identification (outpatient) 1/, 20. Selma C. Kunitz, Ph.D. 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. Ideally, one would also collect income to more fully define socioeconomic status. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. Disposition of Patient (inpatient) 1/, 40. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). 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. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. National Institutes of Health, David . C.Child 38. Ronald Carlson These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. American Medical Association, Herbert G. Traxler, Ph.D. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. 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. Elliot M. Stone, M.V.C. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. 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. 200 Independence Avenue, SW Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. The UACDS is a recommended set, not a mandatory one. What clinical information is collected in the Uhdds? Most organizations were supportive in wanting to 'get on board' with standardized data elements. College of Nursing, East Tennessee State University, Jimmy Thomas Efird Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. 17-23. Massachusetts Department of Public Health, Richard H. Friedman HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. 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. 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. See Page 1. Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. New York State Office of Mental Health, James T. Howell, MD National Association of Health Data Organizations. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. One major reason is the staff and dollar resources required to travel to and participate in several meetings per group per year. What does ambulatory care include? To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. 02. 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. Future projects may undertake to seek consensus among some of these items. 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. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. In addition, a number of elements for which consensus is close, must be field tested to confirm their definitions and collectibility. Hartford Health Department, Clem McDonald, M.D. 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. The immediate goal of the NPI/NPF project is to support HCFA's Medicare Transaction System initiative by providing a single, universal method for enumerating the providers who serve Medicare beneficiaries. Sufficient penalties for breach of confidentiality either do not exist or are not enforced. Georgia Center for Health Information, Patricia K. Miller 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. 34. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. University of California--San Francisco, Marlene M. Lugg Grouping of similar services provided on different dates, as is often the case under batch billing, can be problematic if specificity of data elements is lost; the objective is to encourage identifying a unique date of record for each encounter. 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. 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. DCPC/NCCDPHP/CDC, Raymond C. Zastrow 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. Currently there is little or no input from the public health field for several reasons. Problems could arise from adding and modifying data items and definitions too frequently. Illinois Department of Public Aid, Amanda Attridge Henson The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. 1. Which is a data element of the Uniform Ambulatory Care data set Uacds )? Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. 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. The Committee recommends that the HCFA identifier be adopted when completed. Support the NCVHS continuing its work in this area, especially using its expertise to discuss research issues, to assist in consensus building, and to participate with the Data Council in the implementation of the core data element project recommendations. 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. 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. The Committee encourages the development of one taxonomy and will monitor progress. Date of Encounter (outpatient and physician services) - Year, month, and day of encounter, visit, or other health care encounter, as recommended by the UACDS and ANSI ASC X12. There may be more than one health care provider identified: A.The health care practitioner professionally responsible for the services, including ambulatory procedures, delivered to the patient (health care practitioner of record) Attending Physician Identification (inpatient) 1/, 22. American Psychiatric Association, Thomas C. Sawyer HRSA, Bureau of Primary Care, Mary Reister However, a place holder for this element is recommended to the standards-setting organizations. Regenstrief Institute, Dora A. McDonald Confidentiality of identifiable records is another critical issue. Where can I watch the entire Dragon Ball series for free. 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. 36. National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. ASTM Committee E-31, Clifford P. Binder 20. 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. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. 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. The Committee recommends the following actions specifically related to the core data elements: 3. 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. Injury Related to Employment - Yes, No. 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. Sex, age, and race of the patient. 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). It is important to note for this report, however, that the two subcommittees are in agreement with the core data elements that are described herein. 27. UACDS. 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. Departmental work and should be reported instrument for measuring the functional status of children too.... Set ( UACDS ) regulates Ambulatory Care data set UACDS ) the NPI of Alcohol, Abuse and... Guidelines are used by hospitals to report inpatient data elements unique identifier does not necessarily mean that the is! 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