25. 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). Elliot M. Stone, M.V.C. Kaiser Foundation Health Plan, Matthew McKearn The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. 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 Committee feels that, over time, there will be increasing attention focused on this item and reaffirms its recommendations in the 1994 revisions to the UACDS that additional study and evaluation be conducted on the feasibility and utility of collecting and periodically updating information on a person's occupation and industry. Health Care Practitioner Identification (outpatient), 21. 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. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. The MEDSTAT Group, Joel Diringer, JD. Birch & Davis Health Management Corporation, Inc. George F. Grob Massachusetts Department of Public Health, Richard H. Friedman Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. Circulate the report within the Department for review and constructive criticism. Disposition of Patient (inpatient) - As recommended by the UB 92 and as an expansion of the 1992-93 UHDDS data element: A.Discharged to home or self care (routine discharge) Virginia Health Information, Charles MacKay Patient's Expected Sources of Payment 1/. 3. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. As a result of the process followed in the conduct of this project and based on careful analysis by its members, the Committee has reached the following conclusions: Because they recognize the significance of this project, respondents also recommended a number of additional items that they would like evaluated and possibly included in a core set of standardized data elements. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Computer Network Architects, Inc. Barry Gordon What does UACDS stand for? Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. We use cookies to ensure that we give you the best experience on our website. Office of Inspector General. The National Association of Health Data Organizations has also opposed such an inclusion. 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. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. 02. 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. Support implementation and testing activities for those data elements for which agreement on definitions has been reached and those for which minimal additional work is needed on definitional agreement. Support the NCVHS 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 data element project recommendations. 5. Which of the following data elements is unique to UACDS A. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . In order to have as wide a participation at the meeting as possible, both East and West coast meetings were held in Oakland, CA, in early November, and in Washington, DC, in early December. Additional evaluation and testing are warranted for this important information. These activities could take several forms. Previous experience indicates that at least some, if not many, of these data items have differing definitions. To transmit electronic data C. To create a process for transmitting data to external users D. 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. NYLCare Health Plans, Inc. Eugene Stanton UACDS. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. They have influenced the claim forms on which Medicare and Medicaid data sets are based. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. In addition, the historical knowledge of the NCVHS and its earlier decisions in the area of data standardization played a role in the preparation of a listing of core data elements and, where possible, recommended definitions. 19. 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. Department of Veterans Affairs, John A. Hornik, Ph.D. Work on this topic is currently ongoing in the NCVHS Disability and Long-Term Care Statistics Subcommittee. The currently recommended coding instrument is the ICD-9-CM. Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. 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. Attending Physician Identification (inpatient) 1/, 22. 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. 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) It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. 29-30. 200 Independence Avenue, SW United States Department of Agriculture, Food and Nurtrition Service. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. It will also serve as a quality check as the date of birth approaches the new century mark. Another issue was the role of the National Committee itself as the source of information on common data elements. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. The Committee encourages the use of the above definition, while continuing to study and evaluate other residential categories, such as those used by the Bureau of the Census. Uniform Ambulatory Care Data Set. The .gov means its official. Therefore, billed charges should be collected, at a minimum. Association of State and Territorial Health Officials, D. Walter Biggs, III 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. National Institutes of Health, Stanley C. Garnett New York State Office of Mental Health, James T. Howell, MD 11. National Center for Health Statistics. 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From the respondents, a total of 138 different data elements were obtained. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. To retrieve electronic data B. To measure the current state of the use of various data sets, the Committee contracted with the Center for Health Policy Studies (CHPS) in Columbia, MD to begin identifying major data sets already in existence, especially in the private field. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. The draft systems requirement definition was issued in January, 1995. Columbia/HCA HealthCare Corporation, John Quinn Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. National Institutes of Health, David . B.Discharged/transferred to another short term general hospital for inpatient care Deborah Lieberman, MHSA, OTR/L, PAOTA Other recommendations will be circulated for comment at a future time. Kunitz and Associates, Inc. Laura B. Landrum The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. Principal diagnosis is required by most systems for inpatient reporting. 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. HRSA, Bureau of Primary Care, Mary Reister For children under the age of 18, the mother's highest grade of schooling completed should be obtained. G.Discharged/transferred to home under care of a Home IV provider 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. Thomas P. Gross, M.D., MPH Which of the following data elements is unique to Uhdds quizlet? Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. Department of Public Health, Dan Rode Some recommendations in the area of mental health and substance abuse are included here. University of Iowa. Much of the required information can be located on the patients face sheet. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. 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. Emily Friedman Health Policy Analysis, Del Fulgencio 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. American Medical Association, LaVerne D. Knezek, Ph.D. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. 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. The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. Paul L. Grimaldi, Ph.D. 6. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. The Committee has recognized that data confidentiality is a major concern in the collection of health data from an increasing number of sites, and the Committee has long been concerned with personal privacy and data confidentiality issues. MPH 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. Current or Most Recent Occupation and Industry 2/, 16. The Committee recommends that the HCFA identifier be adopted when completed. Office of the Assistant Secretary for Planning and Evaluation. The Commonwealth of Massachusetts, Rate Setting Commision, Daniel J. Friedman, Ph.D. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. American Nurses Association, Larry W. Miller 10. In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. Functional Status - The functional status of a person is an increasingly important health measure that has been shown to be strongly related to medical care utilization rates. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. There is less agreement on data definitions, even for data items that have been in the field for years. BlueCross BlueShield of Minnesota. 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 System of West Virginia, Curtis O. Porter Congress of the United States, Emilie Schmeidler, Ph.D. Uniform hospital discharge data set (UHDDS). It is recommended that convergence of these guidelines be investigated. Centers for Disease Control and Prevention. The Committee recommends the following actions specifically related to the core data elements: 3. 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. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. 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. Which of the following data elements is unique to UACDS A. 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. The intent is not to specify a data set for mandated external reporting; the list of recommended data elements is by no means exhaustive, and, unlike earlier activities, is not a "data set" to be used in a specific setting. At the present time, standards- setting organizations should assign place holder(s) for this element. Classify common law marriage as married. See Page 1. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Race and ethnicity 04a. What clinical information is collected in the Uhdds? Department of Health and Human Services, Cheryl Beversdorf A detailed report of these findings is in the process of publication by AHCPR, but findings have shown that even well-recognized standards are not consistently followed. 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. Children's Memorial Hospital, Ernest J. Sessa The Committee encourages the development of one taxonomy and will monitor progress. A person who has never been married or whose only marriages have been annulled. 22. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. Each encounter generates a date of service that can be used to link encounters for the same patient over time. Future projects may undertake to seek consensus among some of these items. compare data for inpatients and ambulatory patients in the same or among other facilities. Source of payment categories, as recommended in the past, are no longer sufficient. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. Significant medical procedures performed. Updates of activities in each of the agencies are presented to the Committee on a regular basis. 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. Shortly after arrival in the ER, the patient's. University of California. 27. C.Discharged/transferred to skilled nursing facility (SNF) 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. ICD-10-PCS code for: 1. 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. Health Care Financing Administration, Steven M. Melov Health Care Financing Administration, Steven B. Cohen 35. FACEP Race and ethnicity B. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. The Alan Guttmacher Institute, Kathleen A. Frawley In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. Injury Related to Employment - Yes, No. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. The latter element, which describes all conditions requiring evaluation and/or treatment or management at the time of the encounter as designated by the health care practitioner, has been divided into two elements: 1) the diagnosis chiefly responsible for services provided, and 2) other diagnoses. Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). 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. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. As recommended by the UHDDS and the UACDS. 21. 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). Much of the required information can be located on the patient's face sheet. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. 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.
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