Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. The latter element, which describes all conditions requiring evaluation and/or treatment or management at the time of the encounter as designated by the health care practitioner, has been divided into two elements: 1) the diagnosis chiefly responsible for services provided, and 2) other diagnoses. Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. 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. Patient's Expected Sources of Payment, 12. The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. Self-report and clinician measurements are each valuable, and having both available is especially informative. 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. A total of 31 responses were received. Capture of the full four-digit year of birth is recommended 03. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. The following list of data elements contains those elements selected for the first iteration of this process. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. 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. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 41. 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. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. 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. Additionally, a consensus must be reached on the unique personal identifier. Ronald Carlson Interregional Services, James P. Cooney, Jr., Ph.D. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. The UACDS is a recommended set, not a mandatory one. Center for Health Policy Studies, Rachael Block 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. every facility where ambulatory care is delivered. 20. 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. D.Other (specify). Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. Standard electronic formats are recommended to the extent that they have been developed. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Department of Agriculture, Theresa Wulbrecht Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. Health Care Practitioner Identification (outpatient), 21. Problem, Diagnosis or Assessment (outpatient). Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Social Security Administration, Andrew A. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. Facility Identification - The unique HCFA identifier as described above. The Committee recommends that the HCFA identifier be adopted when completed. To retrieve electronic data B. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. Georgia Center for Health Information, Patricia K. Miller The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. Deborah Lieberman, MHSA, OTR/L, PAOTA In the early 1990's, it formed an Ad Hoc Work Group on Confidentiality to study issues related to confidentiality, unique personal identifiers and data linkage across time and systems. 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. https://www.health-improve.org/what-is-uacds-in-healthcare/ Regenstrief Institute, Dora A. McDonald 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. Information is collected by a wide range of users and in a myriad of different formats. Shortly after arrival in the ER, the patient's. 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). 30. Congress of the United States, Vicki Hohner A large number were collected by only a few of the data sets. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. 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. Some recommendations in the area of mental health and substance abuse are included here. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich Gender - Male, Female. Additionally, includes optional data elements to describe the patients living arrangements and marital status. In some instances, lists of items were received with many basic data items not included. Applied Medical Data, Inc. Kenneth L. Evans, M.D. Principal Procedure (inpatient)- As recommended by the UHDDS, the principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. For example, the State of California, in testimony to the NCVHS, described its efforts in improving health and health care delivery by linking data collected through medical facilities, school-based health and educational data bases, as well as need-based data bases such as eligibility listings for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) or reduced school-lunch programs. 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. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. 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. Promote consensus by identifying areas of agreement on data elements and data sets among different stakeholders and areas that will require further research and development before consensus can be reached. 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. Medications Prescribed - Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code, dosage, strength, and total amount prescribed. Managed Behavioral Health News, Melvin Sabshin, M.D. The Committee feels that, over time, there will be increasing attention focused on this item and reaffirms its recommendations in the 1994 revisions to the UACDS that additional study and evaluation be conducted on the feasibility and utility of collecting and periodically updating information on a person's occupation and industry. UACDS. 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. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. jr pk hg ws qk bc qp wi Describe each data set element, who developed the data set, and compare the similarities and differences of each data set to the others for the following 3 data sets Uniform Hospital Discharge Data Set (UHDDS) for inpatients Uniform Ambulatory Care Data Set (UACDS) for outpatient or ambulatory patients Minimum Data Set (MDS) for long-term care. The increasing use of electronic data, the evolving managed care field, and the growing requirement for performance monitoring and outcomes research have made it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. Bureau of Vital Records and Health Statistics. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. National Indian Council on Aging, Inc. Jacqueline R. Bennett 35. Consensus building on data elements and definitions was, as always, a complex issue. From the respondents, a total of 138 different data elements were obtained. Disposition of Patient (inpatient) 1/, 40. The UACDS is a recommended set, not a mandatory one. The description of the element indicates this present lack of agreement. Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). ASTM Committee E-31, Clifford P. Binder Michael L. Glickman Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. I need the ICD-10-PCS codes 2. 42. 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. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. Another issue was the role of the National Committee itself as the source of information on common data elements. Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. 6. The University of Illinois at Chicago, Eunice Chee 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. Producing the compendium was a much more involved effort than was originally envisioned, and probably is representative of problems to be overcome in the future when standardization implementation is planned. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. However, a place holder for this element is recommended to the standards-setting organizations. It is recommended that convergence of these guidelines be investigated. Maine Health Information Center, Florence B. Fiori, Dr.P.H. A person who has never been married or whose only marriages have been annulled. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. 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. 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. This group, or a separate group, could also be the focus for evaluating additions to the list of core data elements and for setting up methods for testing and promulgating the final products. Qualifier for Other Diagnoses (inpatient) - The following qualifier should be applied to each diagnosis coded under "other diagnoses," as was recommended in the 1992 revision of the UHDDS: This element is currently being collected by California and New York hospital discharge data systems; there is an indication that use of this qualifier can contribute significantly to quality assurance monitoring, risk-adjusted outcome studies, and reimbursement strategies. It is of vital importance to participate in and/or be members of the numerous data standards groups. 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. The currently recommended coding instrument is the ICD-9-CM. No EP studies. IM System, David Newman, M.D. Paul L. Grimaldi, Ph.D. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. University System of West Virginia, Curtis O. Porter 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. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. Sex Male or female 04. 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. This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. Sex, age, and race of the patient. 40B. University of Iowa. Primary Diagnosis (inpatient) - The diagnosis that is responsible for the majority of the care given to the patient or resources used in the care of the patient. It also may be required to verify benefits. Attending Physician Identification (inpatient) 1/, 22. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. 12. NYLCare Health Plans, Inc. Eugene Stanton Living/Residential Arrangement - The following definitions are recommended by the NCVHS: Multiple responses to this item are possible. Standards groups should be consulted regarding setting criteria for recording of names. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. In addition, information was solicited by the NCVHS through two large-scale mailings, and public meetings were held with agencies and organizations which are currently collecting health data sets. Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. Additional evaluation and testing are warranted for this important information. 1. A detailed report of these findings is in the process of publication by AHCPR, but findings have shown that even well-recognized standards are not consistently followed. Location or Address of Encounter (outpatient), 21. To transmit electronic data C. To create a process for transmitting data to external users D. 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). National Cancer Institute, NIH, Alfred S. Buck, M.D. 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 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. 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. Respondents have indicated a mixed use of this item for inpatients. More emphasis on the confidential use of SSN is essential. 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. 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. 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. 9. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. Examples include information on health behaviors, such as smoking and alcohol consumption; information on preventive services; language ability; severity of illness indicators; provider certainty of diagnostic information; information to link a mother's and infant's charts; information on readmissions and complications. 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. C.Discharged/transferred to skilled nursing facility (SNF) HHS, HCFA, Office of Managed Care, Gordon Bonnyman 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. To retrieve electronic data B. Data quality is a perennial issue. Gender As recommended by the UHDDS and the UACDS. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. Health Level 7 Ernst & Young LLP, Jerri Regan Dept. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. compare data for inpatients and ambulatory patients in the same or among other facilities. 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. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. Operating Clinician Identification (inpatient), 40. 4. However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter. National Association of Health Data Organizations. National Center for Health Statistics, Barbara D. Matula The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. 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.). Currently, such a staff does not exist. Health Resources and Services Administration, William E. Flynn, III States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. Department of Veteran's Affairs (19), Lora Kraus If the HCFA system does not have separate identification numbers for parts of a hospital (i.e., Emergency Department, Outpatient Department), an additional element (such as element 13) will need to be collected along with the facility ID to differentiate these settings. The ICD-9-CM is the recommended coding convention. 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. Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. The Committee supports the HHS Data Council in its formation of the Health Data Standards Committee to focus attention on the needs for standardized data both within the Department and in the health care community at large and to foster collaboration and consensus with the major standards-setting organizations. Confidentiality of identifiable records is another critical issue. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Four digits are recommended for the discharge year. 27. Some of these included information on health behaviors, such as smoking and alcohol consumption; information on preventive services; language ability; severity of illness indicators; provider certainty of diagnostic information; information to link a mother's and infant's charts; information on readmissions and complications, to mention a few. Which data is collected on Medicare and Medicaid patients? The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Larry Deutsch, M.D., M.P.H. Therefore, billed charges should be collected, at a minimum. Illinois Department of Public Aid, Amanda Attridge Henson Which of the following data elements is unique to UACDS A. A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. 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. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). 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. 5. FACEP These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. University of California--San Francisco, Marlene M. Lugg It is possible that the description of functional status may entail more than a single measure, thus needing space for more than one measure and/or an additional element to document the scale used. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. (Currently approximately 40 states collect health data on inpatient hospital stays.) Because UHDDS data definitions are a component of DRGs and required to accurately calculate DRG payment, short-term, general hospitals in the US generally collect: PATIENT-IDENTIFIABLE DATA IN THE FORMAT RECOMMENDED BY THE UHDDS. Uniform Ambulatory Care Data Set (UACDS). What does ambulatory care include? The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. There is already consensus among data collectors and users for a significant number of data elements, especially elements related to person descriptors and to selected information on inpatient and ambulatory encounters. 17-23. American Health Information Management Association, Louis I. Freedman