Department of Agriculture, Theresa Wulbrecht State of Florida Agency for Health Care Administration, Kathryn Huntley 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. Significant medical procedures performed. Gender As recommended by the UHDDS and the UACDS. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. A total of 31 responses were received. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. They have influenced the claim forms on which Medicare and Medicaid data sets are based. 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. Marital Status - The following definitions, as recommended by the NCVHS, should be used. Whichever method is used should be designated. 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." This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity 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. Support the NCVHS in 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 health data element project recommendations. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. Such a system would be helpful to the extent that it is feasible in the current highly dynamic market. 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. Some states and organizations are on the cutting edge of multiple use of standardized data. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. National Institutes of Health, Stanley C. Garnett 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. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. ICD-10-PCS code for: 1. Gender - Male, Female. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. Information on all patient problems and diagnoses requiring attention at the encounter are needed to assess the quality of care delivered, to determine what types of health problems are being seen and treated in the different types of ambulatory care facilities, and for assessing the appropriateness of the setting used to perform the services. 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) The type of data collected in each different facility's patient health records is established by required standards or regulations. No follow-up planned (return if needed, PRN), Referred elsewhere (including to hospital), No charge (free, charity, special research, or teaching), Mental Health and Substance Use History of Consumer and of Consumer's Family Members, Categorization and Coding of Wrap Around Services (including community-based services, housing assistance, job training, etc.). 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. Armed with the extensive listing of potential data elements culled from the Compendium, in September 1995, the NCVHS contacted approximately 2,000 individuals and organizations in the health care utilization and data fields to seek their input in identifying those basic elements most in need of collection and/or in need of uniform definitions (appendix B). National Committee for Quality Assurance, James S. Todd, M.D. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Medicare and many other payers adhere to these guidelines. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. What is the essential clinical dataset? It might not be feasible to expect the record to be updated to include payment data when it becomes available. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. Other Procedures (inpatient) - All other procedures that meet the criteria described in element 33. White, M.P.H., Ph.D. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? 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. Each item that is recommended must be considered carefully. The UACDS is a recommended set, not a mandatory one. Additional evaluation and testing are needed on standardizing the health status element. Future projects may undertake to seek consensus among some of these items. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. Mactas 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. 19. 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 It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. Years of schooling has been found to be highly predictive of health status and health care use. 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. State of Texas Department of Health, Mike McGinty, Ph.D. 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. Health Care Financing Administration, James Tierney prison), Principal diagnosis of an injury or poisoning. Illinois Department of Public Health, Michael T. Lundberg, B.S. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. 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. 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'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. Children's Memorial Hospital, Ernest J. Sessa Medical and Health Research Association, Gregg A. Pane, M.D. 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.) Interregional Services, James P. Cooney, Jr., Ph.D. A lack of footnote indicates that the element is ready for implementation. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. MPH All have significant value and could result in the collection of four separate data elements. . Health Care Practitioner Identification (outpatient) 1/, 20. 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). Date of Birth Month, day, and year of birth. 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. The Commonwealth of Massachusetts, Rate Setting Commision, Daniel J. Friedman, Ph.D. 4. 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. Paul L. Grimaldi, Ph.D. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. New York, using the last 4 digits of the Social Security Number, with other characteristics (such as date of birth), indicated a match rate exceeding 99 percent. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. 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. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer 11. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. 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. 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. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. 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. UHDDS Today Hospital or facility identification number or code. 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. 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 . BlueCross BlueShield of Minnesota. Larry Deutsch, M.D., M.P.H. 28. Uniform Ambulatory Care Data Set (UACDS). A person currently married. 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. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. Type of Facility/Place of Encounter. 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. Currently, data are often shared within a facility in an identifiable format. 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). It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. 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. 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. Managed Behavioral Health News, Melvin Sabshin, M.D. Disposition of Patient (inpatient) 1/, 40. With the assistance of the Center for Mental Health Services, SAMHSA, and a contractor, Webman Associates, a study was undertaken to identify and survey a representative sample of mental health, managed care, substance abuse, disabilities and long term care experts who would be willing to offer recommendations about the content of an ideal minimal data set for a health care record that is inclusive of the relevant information. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. Sufficient penalties for breach of confidentiality either do not exist or are not enforced. 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. Vermont Health Care Authority, Michael G. Kassis 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. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. In addition, the usefulness of both current/most recent occupation and industry as well as the addition of usual or longest held occupation and industry must be evaluated. 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. Type of Facility/Place of Encounter 1/, 19. It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. 12. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Compelling evidence presented by the Indian Health Service, states and nonprofit organizations demonstrates that effective intervention strategies can be implemented in response to available data on external causes of injury. Another form would be through an organization that already has a WEB page; several organizations indicated that they would be willing to test the sharing of this information through their Internet sites. 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. National Association Children's Hospitals, George Arges 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. If you continue to use this site we will assume that you are happy with it. Condition(s) should be recorded to the highest documented level of specificity. Other recommendations will be circulated for comment at a future time. Concurrent with these activities being undertaken by the full Committee, there are two related projects undertaken by the Subcommittee on Mental Health Statistics and the Subcommittee on Disability and Long Term Care Statistics. 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. UNIFORM AMBULATORY CARE DATA SET. Much of the required information can be located on the patients face sheet. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. 38. 6. 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. Date of Encounter (outpatient and physician services) - Year, month, and day of encounter, visit, or other health care encounter, as recommended by the UACDS and ANSI ASC X12. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. During the discussion on including External Cause of Injury in the 1994 revision to the UACDS, CDC and labor and business groups urged collection of whether or not an injury occurred at work or was work-related. NYLCare Health Plans, Inc. Eugene Stanton One major reason is the staff and dollar resources required to travel to and participate in several meetings per group per year. Kaiser Foundation Health Plan, Matthew McKearn Of these, approximately 70 percent provided information about their data elements. 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. A large number were collected by only a few of the data sets. 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. National Center for Health Statistics, Richard Rubin An example of this could be NAHDO which could undertake to work with its members. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. 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). [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. Patient's Stated Reason for Visit or Chief Complaint (outpatient). A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. Those present at the November and December 1995 NCVHS regional meetings agreed that the establishment of a unique identifier is the most important core data item. The Committee recommends that the HCFA identifier be adopted when completed. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. 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. Where can the Uhdds data elements be found? Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). National Institutes of Health, David . 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