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. Rating: 1. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. National Association Children's Hospitals, George Arges Therefore, billed charges should be collected, at a minimum. A commonly used measure is the person's rating of his or her own general health, as in the five-category classification, "excellent, very good, good, fair, or poor." The currently recommended coding instrument is the ICD- 9-CM. James Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the addition of a single data item. The currently recommended coding instrument is the ICD-9-CM. Center for Health Policy Studies, Carrie Dunkle, RN 20. To retrieve electronic data B. 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. 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. American Society of Ophthaimic Registered Nurses. Larry Deutsch, M.D., M.P.H. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich Additionally, too frequent modification of items or definitions will cause confusion, overlapping data definitions in a single data year, and add to the burden of the facility or organization. National Center for Health Statistics, Richard Rubin 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: Hi there, would you like us to [] Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. The site is secure. Paul Y. Ertel, M.D. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. The complete address of the providers office. 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. 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. Although 61 requests were made regarding data sets, almost one-third of respondents indicated that they did not have a set of health data items that they collected. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. prison), Principal diagnosis of an injury or poisoning. Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey Indian Health Service, Robert Davis University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS. Most organizations were supportive in wanting to 'get on board' with standardized data elements. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. University of Iowa. American Medical Association, Zili Sloboda, Sc.D. BlueCross BlueShield of Minnesota. The goal is to see what commonalities already exist and to what extent there can be further movement toward greater commonality of terms and consistency of definition. 4. The State of California has tested the use of a series of data items that are readily known by individuals and which can be combined to link data. Workgroup for Electronic Data Interchange, Lucy Johns 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. Massachusetts Department of Public Health, Richard H. Friedman A series of matrices were prepared that arrayed individual data elements in use or proposed for use by different organizations with the type of organization. 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). Other recommendations will be circulated for comment at a future time. Type of Encounter - This element is critical to the placement of an encounter of care within its correct location, i.e., hospital inpatient , outpatient, emergency department, observation, etc. Phillippine Nurses Association of America, Karen Grady 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. 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. 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. It is recommended that convergence of these guidelines be investigated. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 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. 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. 1. 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. 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. The report provides important background information on coordinators and promoters of standards development; lead standards-development organizations; organizations developing performance measures indicators; departmental organizations; international organizations; and others. 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. National Center for Health Statistics. Public and private participants have indicated a willingness to work together to disseminate information, test data elements, and utilize electronic means to ensure the widest dissemination of these activities. Of 18 trade or professional associations contacted, only four submitted data sets. Injury Related to Employment - Yes, No. Who will have access to the database for research purposes, and to what data, has yet to be determined. National Cancer Institute, NIH, Alfred S. Buck, M.D. Regenstrief Institute, Dora A. McDonald 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. They currently are not developing a system of categories to accompany the IDs. State of Texas Department of Health, Mike McGinty, Ph.D. It is the expectation of the Committee that the health care field will find these recommended data elements to be fundamentally important for any collection of person and health care encounter data and will consider these elements and standardized definitions for inclusion in their data collection efforts wherever possible. 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. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. The National Association of Health Data Organizations has also opposed such an inclusion. It is planned that enumeration of Medicare providers will begin in calendar year 1996. Uniform Ambulatory Care Data Set. Health Care Practitioner Specialty 1/, 27. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Applied Medical Data, Inc. Kenneth L. Evans, M.D. 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 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. Confidentiality of identifiable records is another critical issue. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. Definitions must be refined and made available in standardized formats to data collectors. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. 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The following list of data elements contains those elements selected for the first iteration of this process. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. 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. Attending Physician Identification (inpatient), 22. Four digits are recommended for the discharge year. Additional evaluation and testing are needed on standardizing the health status element. A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. Some recommendations in the area of mental health and substance abuse are included here. C.Child 36. 42. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution Office of Inspector General. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. American Public Health Association, Linda Vader, RN, CRNO 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. D'Angelo, B.S., M.S. University of Pennsylvania Medical Center, Steven Kappel On that same day NCVHS submitted to the DHHS Data Council its recommendations for standardizing 42 core health data elements, including demographic, socioeconomic, and health status information about a person and data specific to a person's encounter with the healthcare system on either an inpatient or outpatient basis. University of California--San Francisco, Marlene M. Lugg Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock 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. American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. Catherine McCabe Patient's Stated Reason for Visit or Chief Complaint (outpatient). State of New Jersey Department of Health, Dennis Duffy If a reporting entity is using a different element or definition, explain why their current usage is preferable. American Hospital Association, Dawn Carlson, Ph.D. National Highway Traffic Safety Administration, Amy Fine ASTM (American Society for Testing and Materials ). 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. Race and ethnicity B. National Academy for State Health Policy, Marie Roberto, Dr.P.H. Emily Friedman Health Policy Analysis, Del Fulgencio 14. National Center for Health Statistics, Walter P. Bailey every facility where ambulatory care is delivered. Additionally, a consensus must be reached on the unique personal identifier. Health Care Financing Administration, Steven M. Melov 10. 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. The Committee recommends that the HCFA identifier be adopted when completed. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. An official website of the United States government. State of Florida Agency for Health Care Administration, Kathryn Huntley NYLCare Health Plans, Inc. Andrew Webber Washington, D.C. 20201, U.S. Department of Health and Human Services, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Collaborations, Committees, and Advisory Groups, Physician-Focused Payment Model Technical Advisory Committee (PTAC), OS-Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, Core Health Data Elements: Report of the National Committee on Vital and Health Statistics. 15. Data elements used in UACDS are provider Identifications, address, type of practice, which includes the full name of the provider as well as the unique physician identification number (UPIN). The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. However, the activities envisioned by many participants go much farther than an advisory committee can handle. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. Health Care Financing Administration, James Tierney Illinois Department of Public Health, Frank C. Lemus Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. Core Health Data Elements Project 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. An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. Minnesota Department of Health, Trish Riley 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. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Colorado Hospital Association, Nancy Breen, Ph.D. Where can the Uhdds data elements be found? To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. 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.). Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. The American Academy of Family Physicians, Barbara Faigin Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Consensus building on data elements and definitions was, as always, a complex issue. See Page 1. 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. What does ambulatory care include? 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. It also may be required to verify benefits. Illinois Department of Public Health, Michael T. Lundberg, B.S. 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. UHDDS Today Hospital or facility identification number or code. Health Care Financing Administration, Brenda Spillman University of Virginia. A person currently married. The intent is not to specify a data set for mandated external reporting; the list of recommended data elements is by no means exhaustive, and, unlike earlier activities, is not a "data set" to be used in a specific setting. 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