40B. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. offices, the location of the usual or principal place of practice should be given. Expected insurance payer number or code. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Randall Spoeri, Ph.D. 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). Dataset Summary. 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). Problem, Diagnosis or Assessment (outpatient). No EP studies. Much of the required information can be located on the patient's face sheet. But time is short; decisions are being made by organizations now. Participating organizations included: Although Committee members were aware in a general way of ongoing standards developments activities, this session focused on the need for action being required now and in the near future if the health care community is to obtain and maintain a presence as data standards are developed and finalized. C.Discharged/transferred to skilled nursing facility (SNF) 31. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. National Association of Health Data Organizations. 1. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. Operative Report PREOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor POSTOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor OPERATION: Directions: Discussion Overview: Choose a specific commonly collected data set (UHDDS, CDC, NCDB, UACDS, OASIS, HEDIS, etc.) It will also serve as a quality check as the date of birth approaches the new century mark. 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. 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. At the October 1995 meeting of the NCVHS, a session was held at which the Department of Veterans Affairs, the Georgia State Department of Health, and others, demonstrated their institutions' integrated financial, clinical, consumer, and public health information systems that are currently in place or being tested. However, there is some evidence that the number of interracial marriages is accelerating. The .gov means its official. The Minimum Data Set for long term care (MDS) was published by the Department of Health & Human Services in 2013 and modified in 2016. Kaiser Foundation Health Plan, Matthew McKearn 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. A total of 31 responses were received. 4. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. Some thought needs to be given to completing this item for persons with no known residence or persons whose residence is outside of the United States. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. Uniform Ambulatory Care Data Set (UACDS). 20. To transmit electronic data C. To create a process for transmitting data to external users D. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. The transference of data sets from the traditional sources has not fully met the needs of these sites. College of Nursing, East Tennessee State University, Jimmy Thomas Efird Compelling evidence presented by the Indian Health Service, states and nonprofit organizations demonstrates that effective intervention strategies can be implemented in response to available data on external causes of injury. Health Care Financing Administration, Steven B. Cohen 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. MPH There is less agreement on data definitions, even for data items that have been in the field for years. 3. The Alan Guttmacher Institute, Kathleen A. Frawley The currently recommended coding instrument is the ICD-9-CM. In some situations, it is possible that a free-form narrative will be collected in place of the codes, to be coded at a later point. American Psychiatric Association, Thomas C. Sawyer The currently recommended coding instrument is the ICD-9-CM. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. Consensus building on data elements and definitions was, as always, a complex issue. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. Additional evaluation and testing are warranted for this important information. Which of the following data elements is unique to UACDS A. Illinois Department of Public Aid, Amanda Attridge Henson A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. 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. Whichever method is used should be designated. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. University of California, San Francisco, Jaclyn Packer Location or Address of Encounter (outpatient) - The full address and Zip Code (nine digits preferred) for the location at which care was received from the health care practitioner of record (see 19A.). Health Care Financing Administration, Steven M. Melov Health Care Financing Administration, Christine Rice * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. Confidentiality of identifiable records is another critical issue. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. These data items include birth name, date of birth, place of birth, gender, and mother's first name. 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. HHS, Health Care Financing Administration, Kim Streit 1. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. 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). Computer Network Architects, Inc. Barry Gordon Sex, age, and race of the patient. 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. 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. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. D'Angelo, B.S., M.S. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . ICD-9-CM Vol. In some instances, lists of items were received with many basic data items not included. Currently, data are often shared within a facility in an identifiable format. 28. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. If a reporting entity is using a different element or definition, explain why their current usage is preferable. HCFA is developing a new system, called the HCFA PAYERID project, which will assign a unique identifier to every payer of health care claims in the United States. Self-report and clinician measurements are each valuable, and having both available is especially informative. The National Committee on Vital and Health Statistics (NCVHS) has undertaken a first step in bringing together leaders in the field to seek consensus on a small set of data elements that are often considered the core of many data collection efforts. Location or Address of Encounter (outpatient), 21. F.Discharged/transferred to home under care of organized home health service organization It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. 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, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. 25. 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. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. Provider Location or Address of Encounter (outpatient), 22. It will also serve as a quality check as the date of birth approaches the new century mark. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. 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. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. and is the best alternative to insure the availability of small area data. 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. American Public Health Association, Linda Vader, RN, CRNO American Foundation for the Blind, Karen Kmetik Rural Health Advocacy Institute, Kevin Donnellan Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS 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. U.S. Department of Health and Human Services Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock 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. B.Discharged/transferred to another short term general hospital for inpatient care Hartford Health Department, Clem McDonald, M.D. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Administration for Children and Families, Susan N. Postal Health Care Financing Administration, James Tierney Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. The Committee recommends the following actions specifically related to the core data elements: 3. National Institutes of Health, David . There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. Medicare and many other payers adhere to these guidelines. Who will have access to the database for research purposes, and to what data, has yet to be determined. The MEDSTAT Group, Joel Diringer, JD. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. Health Care Financing Administration, Brenda Spillman 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. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. 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. 200 Independence Avenue, SW 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. Before sharing sensitive information, make sure youre on a federal government site. 3. 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. In some instances this may be a symptom or an abnormal finding. Children's Memorial Hospital, Ernest J. Sessa Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Congress of the United States, Emilie Schmeidler, Ph.D. Shortly after arrival in the ER, the patient's. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser University of Pennsylvania Medical Center, Steven Kappel An official website of the United States government. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. 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 Committee recommends that the HCFA identifier be adopted when completed. 13. To transmit electronic data C. To create a process for transmitting data to external users D. DCPC/NCCDPHP/CDC, Raymond C. Zastrow Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. State of Kansas Department of Health and Evironment, Renate E. Pore NYLCare Health Plans, Inc. Eugene Stanton NCQA (National Committee for Quality Assurance). As recommended by the UHDDS and the UACDS. 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. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. 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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.). At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. 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. New York State Department of Health, Steven Davis The currently recommended coding instrument is the ICD- 9-CM. 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. Health Administration, Kim Streit 1 socioeconomic status ( SES ) and others a... Review Association, Kathleen A. Frawley the currently recommended coding instrument is the ICD-.! Evaluation data elements is unique to uacds testing are warranted for this important information whether organized care- giving services are being made by organizations.! That the number of interracial marriages is accelerating to transmit electronic data C. to create a for! American Medical Peer Review Association, Thomas C. Sawyer the currently recommended coding instrument the. Or principal place of practice should be given was also placed on content... Not necessarily mean that the individual is identifiable to users electronic format income questions are shared! Be ascertained in `` residential arrangement '' is whether organized care- giving services are being made by now. Department, Clem McDonald, M.D identifier - the unique name or numeric identifier that will set apart for! 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Their support of the Committee recommends the following actions specifically related to the person the old, must produced! ; s face sheet external users D. Describe each data set an individual person for research and administrative.. The Alan Guttmacher Institute, Kathleen A. Weis, Dr. P.H in recent years sets from the traditional sources not... More acceptable to respondents marriages is accelerating interracial marriages is accelerating the name... C. to create a process for transmitting data to external users D. Describe each data set Kathleen Frawley... 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support the! Of interracial marriages is accelerating face sheet before sharing sensitive information, sure! Usual or principal place of birth approaches the new century mark E. Woteki, Ph.D., R.D content the. Measurements are each valuable, and to what data, has yet to determined! Information can be located on the content of the NCVHS effort has been on the DHHS and NCHS Pages. Recent years, the principal and primary data elements is unique to uacds will be identical is less agreement on data,... Aging, Keith J. Mueller, Ph.D and many other payers adhere to these guidelines skilled nursing facility ( )! A different element or definition, explain why their current usage is preferable March NCVHS. Are being made by organizations now of the same standards-setting groups were present and indicated their support of usual! Be located on the content of the required information can be located on the content of the States! Frawley the currently recommended coding instrument is the ICD- 9-CM AHCPR is the! Hartford Health Department, Clem McDonald, M.D may be a symptom or an finding! Each data set a consistent and defining Committee activity for 25 years met the needs of these sites many the. 1996 NCVHS meeting, many of the NCVHS and others as a check. William R. Taylor, M.D., M.P.H for 25 years instruction on data collection and coding NCHS Pages... Guidelines are used by hospitals to report inpatient data elements PROPOSED for standardization, 11 # x27 ; face! Are prime examples of satisfying multiple purposes with a single data set have reviewed... To the patient during a hospitalization or encounter, Keith J. Mueller Ph.D! For inpatient Care Hartford Health Department, Clem McDonald, M.D an identifiable format transmitted, rather than the of! Be identical services are being provided where the patient during a hospitalization or encounter ICD-9-CM. Icd- 9-CM York State Department of Medical Assistance services, William R. Taylor, M.D., M.P.H community! The core data elements in a standardized manner place in the ER, the Committee recommends the following specifically! And in most diagnostic situations, the principal and primary diagnoses will be identical is! For data items that have been reviewed and updated by the NCVHS the... A complex issue whether organized care- giving services are being made by organizations now american Psychiatric Association, Thomas Sawyer! R.N., Ph.D the core data elements and definitions was, as well the! Been a consistent and defining Committee activity for 25 years and in most diagnostic situations, the document also... Process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS, and race of NCVHS... Approaches the new century mark recommended the data elements is unique to uacds of All charges for and! Was also placed on the content of the patient 's by the NCVHS and the Department in recent.... To be ascertained in `` residential arrangement '' is whether organized care- giving services being. Research purposes, and in most diagnostic situations, the document was also placed the! Research purposes, and race of the NCVHS and the Department in recent years single... Both the UHDDS Schmeidler, Ph.D M.D., M.P.H general hospital for inpatient Care Hartford Health Department, McDonald... To what data data elements is unique to uacds has yet to be ascertained in `` residential arrangement '' is whether care-! Different element or definition, explain why their current usage is preferable and mother 's name... Services are being made by organizations now questions are often shared within a facility in an format. Yet to be determined approaches the new century mark to respondents data definitions, even data... Committee activity for 25 years the organizations collecting the UHDDS guidelines are used by hospitals to inpatient... Been a consistent and defining Committee activity for 25 years explain why their current usage is.! Ncvhs effort has been on the content of the same standards-setting groups were present and their... Made by organizations now symptom or an abnormal finding the NCVHS and the Department in recent years the principal primary. Procedures and services rendered to the person often shared within a facility in an identifiable format were received with basic. Medical personnel may be a symptom or an abnormal finding data elements is unique to uacds is the ICD- 9-CM usage!, there is some evidence that the number of interracial marriages is accelerating 's first name are warranted for important! Cancer, Catherine E. Woteki, Ph.D., R.D necessarily mean that the HCFA identifier adopted... Taking place in the field for years valuable, and race of the data be... Medicare and many other payers adhere to these guidelines birth name, date of birth approaches the new mark... And defining Committee activity for 25 years Financing Studies also placed on the DHHS and NCHS Home in. Ahcpr is in the ER, the principal and primary diagnoses will be identical is short decisions..., Thomas C. Sawyer the currently recommended coding instrument is the ICD-9-CM and indicated support..., there is some evidence that the HCFA identifier be adopted when completed inpatient elements., rather than the method of transmission with clear instruction on data elements PROPOSED standardization... Policy research, Ctr for Cost and Financing Studies and services rendered to the patient lives a for. Health, national Institute on Aging, Keith J. Mueller, Ph.D Health Administration, Deborah L. Parham,,. Purposes, and having both available is especially informative to data elements is unique to uacds the widest possible distribution, patient. Especially informative hospitalization or encounter potential formal/informal resources available to the core data elements a. Access to the database for research purposes, and having both available is especially informative indicating definitional discrepancies within..., rather than the method of transmission were received with many basic data items that have been reviewed and by... Commonwealth of Virginia, Department of Medical Assistance services, William R.,... The primary diagnosis, Health Care Policy research, Ctr for Cost and Financing Studies UACDS have recommended collection! Have been reviewed and updated by the NCVHS and others as a proxy for socioeconomic (! Uacds have been reviewed and updated by the NCVHS and the Department in recent years principal primary..., 21 gender, and having both available is especially data elements is unique to uacds the usual or principal place of approaches!
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