The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka 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 [] Thomas P. Gross, M.D., MPH The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. Health Resources and Service Admin. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. Operating Clinician identification 1/. 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. 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. 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. 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. 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. Georgia Center for Health Information, Patricia K. Miller 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. Items shown below with an asterisk (*) indicate that this type of information can be obtained from linking the NPI with the National Provider File and may not need separate collection. Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. It will also serve as a quality check as the date of birth approaches the new century mark. 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. Also in March, a consultant to the NCVHS updated the World Health Organization on the core data element activity and returned with input to the process. 8. 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. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. College of American Pathologists, Division of Government and Prof. Affairs. Health Care Financing Administration, Emily Friedman Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. 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. The American Occupational Therapy Association, Inc. Barbara Lowery Additionally, a consensus must be reached on the unique personal identifier. A. National Center for Health Statistics, David P. Winchester, M.D. DCPC/NCCDPHP/CDC, Raymond C. Zastrow 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. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. Standardized data sets can serve many purposes in the current and future health care arena. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. What does UACDS stand for? Include the full name of the provider as well as the National Provider. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 31. A second study is currently underway, one which will investigate core data elements in common use in data sets on persons with disability and/or persons receiving long term care. National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. In accepting these challenges, the Committee seeks to facilitate consensus development and incorporate the concepts of multiple use, continued change, and long-term evolution of core data elements into general thinking and practice. UACDS and UHDDS have many similar data elements, which makes it easier to. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. 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. 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). Thus to meet the needs for standardized data, movement must be made toward standardized definitions for those data sets that are already in use, and for an increased use of standardized data elements and definitions by those data collection efforts for which no current standardized data sets exist. Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment. Much of the required information can be located on the patients face sheet. Gender As recommended by the UHDDS and the UACDS. Race and ethnicity B. Birch & Davis Health Management Corporation, Inc. George F. Grob AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. 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). Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. American Society of Ophthaimic Registered Nurses. 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. The American Academy of Family Physicians, Barbara Faigin The Committee has appointed a liaison to participate in selected meetings of the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X-12, a private sector coalition that is developing transmission standards for health data. 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. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. New York State Department of Health, Steven Davis The Subcommittee determined that residential street address has the advantage of enabling researchers to aggregate the data to any level of geographic detail (block, census tract, ZIP code, county, etc.) The Committee recommends that the HCFA identifier be adopted when completed. The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? A lack of footnote indicates that the element is ready for implementation. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. Which of the following data elements is unique to UACDS? Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. BlueCross BlueShield of Minnesota. Injury Related to Employment - Yes, No. Patient's Stated Reason for Visit or Chief Complaint (outpatient). 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. To retrieve electronic data B. An official website of the United States government. During the October 1995 and March 1996 NCVHS meetings, Dr. Don Detmer, University of Virginia, updated the Committee on international progress in data standardization and computerized patient records. Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. The National Association of Health Data Organizations has also opposed such an inclusion. Race and ethnicity B. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). Columbia/HCA HealthCare Corporation, John Quinn 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. Uniform hospital discharge data set 22. Periodicity of assessment also is an issue. If you continue to use this site we will assume that you are happy with it. 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. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. In addition to requesting a written response from these experts, they were invited to participate in one of two special meetings organized by the Committee to discuss the project and to seek input. 7. Illinois Department of Public Aid, Amanda Attridge Henson 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. What does ambulatory care include? University of California, San Francisco, Jaclyn Packer Standard electronic formats are recommended to the extent that they have been developed. UACDS Data Elements Data Element Definition/Descriptor Provider identification, address, type of practice Place of encounter Reason for encounter Diagnostic services Problem, diagnosis, or assessment Therapeutic services Preventive services Disposition Provider identification: Include the full name of the provider as well as the National Provider Identifier (NPI). 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. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Health Care Financing Administration. Alexis A. Wilson Colorado Hospital Association, Nancy Breen, Ph.D. Center for Health Policy Studies, Carrie Dunkle, RN 1. Race and ethnicity 04a. Health Care Financing Administration, Brenda Spillman Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). 40B. Recommendations and linkage with the current project will be discussed. UACDS. G.Discharged/transferred to home under care of a Home IV provider Because agreement on a unique personal identifier is recognized as a key element to the successful establishment of core data elements, and their use, support the formation of a public-private working group to study and provide recommendations in this area. After review of the data elements collected, the subcommittees decided to study in-depth six data clusters: The preliminary results of this project have been prepared. Legal Services of Middle Tennessee, Leonard Bourget The currently recommended coding instrument is the ICD-9-CM. National Academy for State Health Policy, Marie Roberto, Dr.P.H. Current or Most Recent Occupation and Industry 2/, 16. 17. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. State of New Jersey Department of Health, Dennis Duffy A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. Support implementation and testing activities for those data elements for which agreement on definitions has been reached and those for which minimal additional work is needed on definitional agreement. 37. Which of the following data elements is unique to UACDS A. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman 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 identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. 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. Mactas The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). B.Discharged/transferred to another short term general hospital for inpatient care Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. Don L. Zimmerman, Ph.D. IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. C.Child Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Health Care Practitioner Identification (outpatient), 21. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. 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. ANSI HISPP (Health Informatics Standards Planning Panel). This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. The major objectives of this project include the production of a report assessing existing data for care provided to persons with disabilities in institutional and community long term care settings, as well as in rehabilitation. 27. It became obvious early in the meetings that the identification of core data elements, their definitions, and the consensus-building needed to encourage use of these items would be an ongoing and full-time activity for several years. North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes U.S. Department of Health and Human Services California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN But time is short; decisions are being made by organizations now. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. Current or Most Recent Occupation and Industry, 28. 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. The Alan Guttmacher Institute, Kathleen A. Frawley Consensus building on data elements and definitions was, as always, a complex issue. What is Uacds? National Institute on Drug Abuse, Cille Kennedy Also, although different data sets may include the same data element, in most cases it was not possible to verify that the data collection instructions and definitions were the same. Michael L. Glickman Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. 41. every facility where ambulatory care is delivered. FACEP Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. 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. Health Care Practitioner Identification (outpatient) 1/, 20. University of Iowa. Kunitz and Associates, Inc. Laura B. Landrum 1. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. Catherine McCabe Association of Maternal and Child Health Programs, Karl S. 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