A data element is defined by size (in characters) and type (alphanumeric,. 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. In a number of instances, lists of data items were obtained, but without definitions. New York State Department of Health, Steven Davis It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. National Highway Traffic Safety Administration, Amy Fine University of Iowa. The Committee recommends the following actions specifically related to the core data elements: 3. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. 29. 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." These activities could take several forms. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. 37. 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); Obtain input, through hearings and other means, from the diverse parties who will report and use standardized data sets; Interact closely with recognized standards-setting groups; and. Because agreement on a unique personal identifier has been 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. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. 33. 18. We use cookies to ensure that we give you the best experience on our website. Department of Health and Human Services, Cheryl Beversdorf Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. 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. The transference of data sets from the traditional sources has not fully met the needs of these sites. Date of Birth Month, day, and year of birth. F.Discharged/transferred to home under care of organized home health service organization Hartford Health Department, Clem McDonald, M.D. No EP studies. Congress of the United States, Vicki Hohner Which of the following data elements is unique to UACDS A. 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. Currently, such a staff does not exist. American Nurses Association, Larry W. Miller 3. HHS, Health Care Financing Administration, Kim Streit Uniform Ambulatory Care Data Set. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. 4. 17-23. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. 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. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. D.Other (specify). The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. 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. A large number were collected by only a few of the data sets. 1. 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. Phillippine Nurses Association of America, Karen Grady It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Used in the National Health Interview Survey and many other studies, this item has been shown to be predictive of morbidity, mortality, and future health care use, when collected in a general interview type of setting. In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. Significant medical procedures performed. Other recommendations will be circulated for comment at a future time. 32. This project has brought together efforts from several state agencies, including education (for the school data), agriculture (the source of WIC data in some states), as well as health departments. There may be more than one health care provider identified: A.The health care practitioner professionally responsible for the services, including ambulatory procedures, delivered to the patient (health care practitioner of record) Center for Health Policy Studies, Rachael Block APHA American Public Health Association, Katherine M. McCormack This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. 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.) Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. Additional evaluation and testing are warranted for this important information. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. 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. NCQA - National Committee for Quality Assurance, Yvonne Senturia, M.D., M.Sc. B.Discharged/transferred to another short term general hospital for inpatient care Where can the Uhdds data elements be found? University of California. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. Years of schooling has been found to be highly predictive of health status and health care use. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Health Care Financing Administration, Steven B. Cohen HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. American Occupational Therapy Association, Kitty Werner 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. Federal government websites often end in .gov or .mil. 28-31. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. G.Discharged/transferred to home under care of a Home IV provider Each item that is recommended must be considered carefully. American Public Health Association, Linda Vader, RN, CRNO To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . 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. 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. ASTM (American Society for Testing and Materials ). 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 [] Anonymous Which data is collected on Medicare and Medicaid patients? Kaiser Foundation Health Plan, Matthew McKearn Type of Facility/Place of Encounter 1/, 19. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock 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. Medicare decided a PAYERID was needed because of the difficulty its contractors were having in transferring claims to other insurance companies, due to incomplete information or multiple names for payers. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. Larry Deutsch, M.D., M.P.H. Living/Residential Arrangement - The following definitions are recommended by the NCVHS: Multiple responses to this item are possible. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. Four digits are recommended for the discharge year. 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 . 40B. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. It is recommended that the year of birth be reported in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. 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. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. 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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. 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) HRSA, Bureau of Primary Care, Mary Reister Department of Public Health, Dan Rode 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. Just trying to obtain data from some large organizations was quite difficult; responses were not received in a timely fashion, and when received, the data layouts often were computerized lists rather than lists of data items with their definitions. 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. To transmit electronic data C. To create a process for transmitting data to external users D. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. American Foundation for the Blind, Karen Kmetik Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN The set includes reasons for the encounter, living arrangements, and marital status. Race and ethnicity 04a. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. Mactas The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. 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. Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. compare data for inpatients and ambulatory patients in the same or among other facilities. If you continue to use this site we will assume that you are happy with it. If a reporting entity is using a different element or definition, explain why their current usage is preferable. 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. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. Massachusetts Department of Public Health, Richard H. Friedman Maine Health Care Finance Commission, Harriet Starr National Cancer Institute, NIH, Alfred S. Buck, M.D. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. From the respondents, a total of 138 different data elements were obtained. University of California, San Francisco, Jaclyn Packer The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. 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. National Institute of Occupational Safety and Health, Stewart H. Streimer Conditions should be coded that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital or nursing home stay; or increased nursing care and/or monitoring. American Hospital Association, Edward W. Bacon St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. The elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter. 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. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell Interregional Services, James P. Cooney, Jr., Ph.D. 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. The usual living/residential arrangement of an individual is important for understanding the health status of the person as well as the person's follow-up needs when seen in a health care setting. 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. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. Sex Male or female 04. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Current or Most Recent Occupation and Industry, 28. UHDDS Today Hospital or facility identification number or code. 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.). More emphasis on the confidential use of SSN is essential. Dept. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. 23. 20. Performance monitoring and outcomes research are two additional areas that are currently hampered by the inability to link data sets from various sources due to varying data elements and definitions. Provide stable resources to the project to establish an interdepartmental work group, with DHHS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. The ICD-9-CM is the recommended coding convention. The response to the Committee's activities both through 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. 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. Congress of the United States, Emilie Schmeidler, Ph.D. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity 5. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Department of Agriculture, Theresa Wulbrecht medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). The MEDSTAT Group, Joel Diringer, JD. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. 17. The personal/unique identifier is the element that is the most critical element to be collected uniformly. HHS, HCFA, Office of Managed Care, Gordon Bonnyman Location or Address of Encounter (outpatient), 21. The Committee's efforts, first in the area of inpatient hospital data (the Uniform Hospital Discharge Data Set or UHDDS) and later in the area of ambulatory care (the Uniform Ambulatory Care Data Set or UACDS) have moved the country in the direction of achieving comparability in the health data collected by federal agencies, states, localities and the private sector, as well as in the international community. ICD-9-CM Vol. 19. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. 11. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. Health Care Practitioner Identification (outpatient), 21. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. C.Child 12. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Legal Services of Middle Tennessee, Leonard Bourget Department of Veteran's Affairs (19), Lora Kraus HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. U.S. Department of Health and Human Services 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. Another issue was the role of the National Committee itself as the source of information on common data elements. Each encounter generates a date of service that can be used to link encounters for the same patient over time. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). 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. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. National Indian Council on Aging, Inc. Jacqueline R. Bennett Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. The University of Illinois at Chicago, Eunice Chee FACEP Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH These same data bases are being used to provide input to Federal surveys such as the National Hospital Discharge Survey (NCHS) and the Hospital Cost and Utilization Project (AHCPR). 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. 10. Operating Clinician Identification (inpatient) 1/, 23. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. 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. New York State Office of Mental Health, James T. Howell, MD Paul L. Grimaldi, Ph.D. The NCVHS recommended this as an optional item in the UACDS but that high priority should be given to conducting additional study as to the feasibility, ease and practical utility of collecting the patient's reason for encounter, in as close to the patient's words as possible. Catherine McCabe Uniform Ambulatory Care Data Set (UACDS). HHS, HFCA, Bureau of Program Operations, Leo J. Nolan 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. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. 14. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. National Perinatal Information Center, Mark J. Segal, Ph.D. Assistant Secretary for Planning and Evaluation, Room 415F 36. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA 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. 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. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. This element refers to living arrangements only. 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. University of Virginia. They currently are not developing a system of categories to accompany the IDs. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. Where can the Uhdds data elements be found? 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. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. The NCVHS recommends the use of Social Security Number with a check item such as date of birth, while at the same time undertaking the study and evaluation needed to confirm this use or the recommendation of another identifier. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. 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. Which of the following data elements is unique to Uhdds quizlet? These data items include birth name, date of birth, place of birth, gender, and mother's first name. Foundation for Health Care Quality, Terry Rudd American Medical Association, Herbert G. Traxler, Ph.D. Thomas P. Gross, M.D., MPH American Medical Association, Cary Sennett, MD, Ph.D. American Medical Association, Mark Epstein, Sc.D. The Committee recommends that the HHS Data Council: 2. 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. Illinois Department of Public Health, Michael T. Lundberg, B.S. Expected insurance payer number or code. The American Occupational Therapy Association, Inc. Barbara Lowery Several major issues were raised that were broader than the discussions of specific data elements. 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. 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. Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. Catherine McCabe Uniform Ambulatory Care following data elements Bureau of Health status and Health Care Policy and Research, for! 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