Department of Agriculture, Theresa Wulbrecht 26. Place holders will be set, and, in some cases data items and definitions decided on, before national and local public health agencies and organizations will be able to act. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. offices, the location of the usual or principal place of practice should be given. Another issue was the role of the National Committee itself as the source of information on common data elements. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. The Committee recommends that the Department fund these activities on an ongoing basis. National Institutes of Health, David . 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. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Principal diagnosis is required by most systems for inpatient reporting. These data assist in the examination of disparities in stage of illness, care, and outcome, some of which have been documented in the past among racial and ethnic groups. Health Care Financing Administration, James Tierney 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. Maine Health Care Finance Commission, Harriet Starr There has been substantial agreement on data elements in these sets, but less agreement on data definitions. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. C.Child 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. 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. St. Peter's Community Hospital, Ron Horner, Ph.D. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. 36. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. 13. National Institute of Dental Research, NIH, T. J. Mathews Participation is voluntary, and HCFA, which is funding its development, has been working to get consensus about the kind of system that would be useful. National Indian Council on Aging, Inc. Jacqueline R. Bennett University of Pennsylvania Medical Center, Steven Kappel 28. Massachusetts Department of Public Health, Richard H. Friedman Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. FACEP "Payers" are defined as public and private entities that have contract responsibility for health care payment. ICD-10-PCS code for: 1. Data Elements UHDDS (Uniform Hospital Discharge Data Set) Personal Identifier A unique number identifying the patient, applicable to the individual regardless of health care source or third-party arrangement. ANSI HISPP (Health Informatics Standards Planning Panel). Purpose: to identify data elements for a uniform minimum data set on ambulatory care CMS1500 (Claim form for Medicare/Medicaid Outpatient claims) is main vehicle used to collect UACDS data elements . American Foundation for the Blind, Karen Kmetik The currently recommended coding instrument is the ICD-9-CM. Paul L. Grimaldi, Ph.D. The database will contain payer names, billing addresses and business information. 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. Carries a procedural risk, or. James Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the addition of a single data item. Deborah Lieberman, MHSA, OTR/L, PAOTA Standards groups should be consulted regarding setting criteria for recording of names. Disposition of Patient (inpatient) 1/, 40. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. State of Florida Agency for Health Care Administration, Kathryn Huntley Congress of the United States, Vicki Hohner The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). Computer Network Architects, Inc. Barry Gordon 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. In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. 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. 8. The personal/unique identifier is the element that is the most critical element to be collected uniformly. Indian Health Service, Robert Davis 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. The description of the element indicates this present lack of agreement. Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). Uniform Ambulatory Care Data Set. Paul Y. Ertel, M.D. 3. Shortly after arrival in the ER, the patient's. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. With the exception of the personal/unique identifier, they do not need to be collected at each encounter. 41. What is the essential clinical dataset? Rating: 1. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. The National Committee is well aware of the numerous efforts currently underway in both the public and private sectors to standardize health data, especially the progress made during the past 10-15 years in developing uniform data sets (Uniform Hospital Discharge Data Set and the Uniform Ambulatory Care Data Set) as well as common claim forms (Uniform Bill 82 and its successor UB 92 and HCFA 1500). Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. 31. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. Several major issues were raised that were broader than the discussions of specific data elements. 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. 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. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman Attending Physician Identification (inpatient) 1/, 22. Another problem is that, although the HHS Data Council has recently established a Health Data Standards Committee, until the past few months, there has been no central location within the Department for monitoring the activities of the data standards groups. 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. 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. 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. American Medical Association, Mark Epstein, Sc.D. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 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. Which of the following data elements is unique to Uhdds quizlet? 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). In some instances this may be a symptom or an abnormal finding. Of 18 trade or professional associations contacted, only four submitted data sets. 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. The transference of data sets from the traditional sources has not fully met the needs of these sites. Which data is collected on Medicare and Medicaid patients? Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. And now, with movement toward HMO's, PPO's, and other types of managed care, there may be a greater need to share identifiable data. The HCFA Common Procedure Coding System (HCPCS), based on CPT-4, is required for physician (ambulatory and inpatient), hospital outpatient department, and free-standing ambulatory surgical facility bills; however, NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. If a reporting entity is using a different element or definition, explain why their current usage is preferable. Institute for Health Policy Studies, UCSP School of Medicine, Christopher G. Chute, M.D., Dr.P.H. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. 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. Health Care Financing Administration, Steven B. Cohen Association of State and Territorial Health Officials, D. Walter Biggs, III Patient's Stated Reason for Visit or Chief Complaint (outpatient) - Includes the patient's stated reason at the time of the encounter for seeking attention or care. Much of the required information can be located on the patients face sheet. A. Illinois Department of Public Aid, Amanda Attridge Henson The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. Health Care Practitioner Identification (outpatient), 21. Virginia Health Information, Charles MacKay 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. Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND Health Care Financing Administration, Brenda Spillman 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. Standard electronic formats are recommended to the extent that they have been developed. The Committee's intent is not to specify a data set for mandated external reporting; not every element may be needed in a specific collection effort, and these data elements do not represent all of the important data items that are collected in the field or needed for specific applications. Patient's Expected Sources of Payment, 12. 18. Race and Ethnicity - The collection of race and ethnicity have been recommended by the UHDDS and the UACDS, and these elements have a required definition for Federal data collection in Office of Management and Budget (OMB) Directive 15. Department of Veterans Affairs, Assistant Secretary for Policy and Planning, Mary Dufour 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. An example of this could be NAHDO which could undertake to work with its members. Previous experience indicates that at least some, if not many, of these data items have differing definitions. From the respondents, a total of 138 different data elements were obtained. Health Resources and Services Administration, William E. Flynn, III A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. 4. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser 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. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. UACDS. Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. What is Uacds? In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. 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. 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. Columbia/HCA HealthCare Corporation, John Quinn The University of Illinois at Chicago, Eunice Chee Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). College of Nursing, East Tennessee State University, Jimmy Thomas Efird Department of Veterans Affairs, John A. Hornik, Ph.D. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. The type of data collected in each different facility's patient health records is established by required standards or regulations. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan It became obvious that staff dedicated to participating in and monitoring the activities of these organizations is crucial if all relevant voices (including public health and epidemiology) are to be heard. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell The American Occupational Therapy Association, Inc. Barbara Lowery A person currently married. Uniform hospital discharge data set St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. If you continue to use this site we will assume that you are happy with it. At present, there is no widely recognized instrument for measuring the functional status of children. 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. Selma C. Kunitz, Ph.D. The .gov means its official. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC The Committee recognizes that this is an iterative process and has included in these recommendations several elements that have been proposed for standardization, even though no consensus currently exists concerning appropriate or feasible definitions. APHA American Public Health Association, Katherine M. McCormack By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. 24. Which of the following data elements is unique to UACDS A. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. A large number were collected by only a few of the data sets. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. The ever-expanding sites of care, combined with the increasing use of electronic data, make it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. 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. State of New Jersey Department of Health, Dennis Duffy Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. In addition, these efforts have concentrated on individual sites of care, ie., hospital inpatient, physician office, and nursing home, which, until recently, were the traditional sites of most care. National Center for Health Statistics, Walter P. Bailey Facility Identification - The unique HCFA identifier as described above. Patient's Stated Reason for Visit or Chief Complaint (outpatient). Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? Data quality is a perennial issue. 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