data elements is unique to uacds

Current or Most Recent Occupation and Industry 2/, 16. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. 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). As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. 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. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. National Center for Health Statistics. The Committee recommends that the HHS Data Council: 2. Without a universal unique identifier or a set of data items that can form a unique identifier, it will be impossible to link data across the myriad of healthcare locations and arrangements. 20. Which of the following data elements is unique to UACDS A. Functional assessment scales must also be age-appropriate. A lack of footnote indicates that these elements are ready for implementation. Health Care Financing Administration, James Tierney This item attempts to define what actually motivated the patient to seek care and has utility for analyzing the demand for health care services, evaluating quality of care and performing risk adjustment. NYLCare Health Plans, Inc. Eugene Stanton Department of Agriculture, Theresa Wulbrecht Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. 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). Race and ethnicity B. 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. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. This term is one that needs study and evaluation before it can be implemented. Operating Clinician identification 1/. Hartford Health Department, Clem McDonald, M.D. The Minimum Data Set for long term care (MDS) was published by the Department of Health & Human Services in 2013 and modified in 2016. 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. University of California--San Francisco, Marlene M. Lugg St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. These activities could take several forms. 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. 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. The National Committee on Vital and Health Statistics (NCVHS) and the Department of Health and Human Services, which it advises, have initiated and completed the first iteration of a process to identify a set of core health data elements on persons and encounters or events that can serve multiple purposes and would benefit from standardization. Years of schooling has been found to be highly predictive of health status and health care use. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 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. Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers. 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.) Which of the following data elements is unique to UACDS? Attending Physician Identification (inpatient) - The unique national identification number assigned to the clinician of record at discharge who is responsible for the discharge summary, as recommended by the 1992 UHDDS. Qualifier for Other Diagnoses (inpatient), 28. 18. Standard electronic formats are recommended to the extent that they have been developed. Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. Georgia Center for Health Information, Patricia K. Miller Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. Health Care Financial Management Association/ASC X12, Kenneth E. Roos, M.S., M.B.A. Center for Health Policy Studies, Carrie Dunkle, RN Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. United States Department of Agriculture, Food and Nurtrition Service. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. ICD-10-PCS code for: 1. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. To retrieve electronic data B. The priorities for recording an External Cause-of-Injury code (E-code) are: The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . American Hospital Association, Dawn Carlson, Ph.D. It might not be feasible to expect the record to be updated to include payment data when it becomes available. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? 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. The UACDS is a recommended set, not a mandatory one. 23. Specifically, the Department charged the Committee to: In developing a strategy for accomplishing these tasks, the Committee described a context in which the project would be undertaken that included the following issues: The following list of data elements contains those elements selected for the first iteration of this process. Standardized coding schemes, such as the Census Bureau's Alphabetical Listing of Occupation and Industry and the Standardized Occupation and Industry Coding (SOIC) software developed by the National Institute for Occupational Safety and Health, should be reviewed. An official website of the United States government. 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. 38. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. 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. 02. One major reason is the staff and dollar resources required to travel to and participate in several meetings per group per year. Self-report and clinician measurements are each valuable, and having both available is especially informative. 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. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. 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). Race and ethnicity B. National Cancer Institute, NIH, Alfred S. Buck, M.D. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich 10. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. National Committee for Quality Assurance, James S. Todd, M.D. Centers for Disease Control and Prevention, Lynn E. Jensen, Ph.D. 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. Interregional Services, James P. Cooney, Jr., Ph.D. Using items such as first name of mother; first digits of last name; date of birth; place of birth, etc., matches could be obtained without identifying the individual. Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. 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. This item already is collected by most state health data organizations collecting hospital discharge information and offers the only readily available information on the fiscal dimensions of care and the relative costs of different types of care. The American Academy of Family Physicians, Barbara Faigin (Currently approximately 40 states collect health data on inpatient hospital stays.) 4. Which of the following data elements is unique to UACDS A. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). 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. 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. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. 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. Each item that is recommended must be considered carefully. University of California. Georgia State University, Maria Redona Couper A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element. Source of payment categories, as recommended in the past, are no longer sufficient. The continuing expansion of types of payments and the combination of payments within groups is ever changing. A person who has never been married or whose only marriages have been annulled. As recommended by the UHDDS and the UACDS. 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. Indian Health Service, Robert Davis Sex Male or female 04. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional study and evaluation must be undertaken to reach consensus on standardized content and definition. American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. Some third party payers, however, have ignored the guidelines and required facilities and health care practitioners to report a diagnosis that justifies the performance of services being provided. Facility Identification - The unique HCFA identifier as described above. 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. 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. 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. Refer the core health data elements recommendations to the National Uniform Claim Committee for their consideration as they study the issue of uniform data elements for paper and electronic collection in Fall 1996. National Perinatal Information Center, Mark J. Segal, Ph.D. The currently recommended coding instrument is the ICD-9-CM. 35. 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. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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. 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. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. 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. 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. Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH The Committee recommends that the HCFA identifier be adopted when completed. Self-Reported Health Status - There was much interest in documenting health status, one element that can precipitate the demand for health care and help determine the prognosis, although there was no consensus on how its definition should be standardized. Paul L. Grimaldi, Ph.D. NCQA (National Committee for Quality Assurance). Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Medical and Health Research Association, Gregg A. Pane, M.D. 12. Foundation for Health Care Quality, Terry Rudd Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. National Institute of Occupational Safety and Health, Stewart H. Streimer 29-30. The Committee works closely with the National Center for Health Statistics, the Agency for Health Care Policy and Research, and the Health Care Financing Administration (HCFA). The personal/unique identifier is the element that is the most critical element to be collected uniformly. Provider Location or Address of Encounter (outpatient), 22. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. 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. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. Attending Physician Identification (inpatient), 22. Aetna Health Plans, Sheila Horman Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. Gender As recommended by the UHDDS and the UACDS. In recent years, the focus of health care has been shifting to hospital outpatient and other outpatient care, including clinic, hospice and home care, sites for which standardized data collection had not been developed. From the respondents, a total of 138 different data elements were obtained. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . 2. 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. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. 7. H.Left against medical advice or discontinued care. 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. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. A person currently married. Health Care Financing Administration, David L. Hobson Health Care Practitioner Identification (outpatient) 1/, 20. NYLCare Health Plans, Inc. Andrew Webber National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. This element is currently collected on the HCFA 1500 form. A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. 8. Providers, Insurers, and universities represented about 7 percent each. Birth weight of newborn is readily available in the medical record and has singular importance for risk-adjustment outcome studies and health policy development related to maternal and infant health. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. 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. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. In these cases, it is possible that the data items, such as person characteristics, are part of a more basic file kept by the organization, and the information for that file was not included. 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. More emphasis on the confidential use of SSN is essential. Uniform Ambulatory Care Data Set. The NPI/NPF will provide a common means of uniquely identifying health care providers, including institutions, individuals, and group practices, both Medicare providers and those in other programs. The draft listing was again disseminated in early April 1996 (see appendix F) to the original mailing list and especially to those who had provided earlier assistance. ASTM (American Society for Testing and Materials ). 24. 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. D.Discharged/transferred to an intermediate care facility (ICF) The University of Illinois at Chicago, Eunice Chee The currently recommended coding instrument is the ICD- 9-CM. Circulate the report within the Department for review and constructive criticism. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards Problem, Diagnosis or Assessment (outpatient). 4. A data element is defined by size (in characters) and type (alphanumeric,. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. It is planned that enumeration of Medicare providers will begin in calendar year 1996. Four digits are recommended for the discharge year. Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. In August 1994, the Department asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Capture of the full four-digit year of birth is recommended 03. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. The UACDS has never been officially promulgated by the Department, but a 1989 revision by the NCVHS and an Interagency Task Force has been widely circulated, as has a further refinement by the NCVHS in 1994. 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. Be confusing the definitions/uses of principal versus primary Diagnosis the report within organizations... 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