The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. 4. The currently recommended coding instrument is the ICD-9-CM. 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. National Association Children's Hospitals, George Arges A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. American Medical Association, Herbert G. 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University of California. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. Hartford Health Department, Clem McDonald, M.D. Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self Paul Y. Ertel, M.D. National Perinatal Information Center, Mark J. Segal, Ph.D. It is planned that enumeration of Medicare providers will begin in calendar year 1996. Core Health Data Elements Project 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. Members of the Committee and DHHS staff participate when possible, however, the increasing numbers of groups and meetings is problematic from a staff and budget point of view. MPH The currently recommended coding instrument is the ICD- 9-CM. HHS, Health Care Financing Administration, Kim Streit Significant medical procedures performed. ICD-10-PCS code for: 1. A person currently married. 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. Participating organizations included: Although Committee members were aware in a general way of ongoing standards developments activities, this session focused on the need for action being required now and in the near future if the health care community is to obtain and maintain a presence as data standards are developed and finalized. Connecticut Children's Medical Center, Geraldine Oliva This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. Ambulatory Conditions - The elements for ambulatory conditions contain information on the Patient's Stated Reason for Visit and the Problems, Diagnosis, or Assessment, both of which were recommended by the UACDS. The Committee recognizes the need for uniform, comparable standards across geographic areas, populations, systems, institutions and sites of care to maximize the effectiveness of health promotion and care and minimize the burden on those responsible for generating the data. HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. The information that this element provides on the causes of patients' injuries or adverse effects is considered essential for the development of intervention, prevention and control strategies. It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. State of Texas Department of Health, Mike McGinty, Ph.D. 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. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. American Public Health Association, Linda Vader, RN, CRNO Currently there is little or no input from the public health field for several reasons. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. Congress of the United States, Vicki Hohner Children's Memorial Hospital, Ernest J. Sessa 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. 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. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. APHA American Public Health Association, Katherine M. McCormack Previous experience indicates that at least some, if not many, of these data items have differing definitions. 26. 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. C.Child Interregional Services, James P. Cooney, Jr., Ph.D. Illinois Department of Public Health, Frank C. Lemus UACDS. Legal Services of Middle Tennessee, Leonard Bourget The personal/unique identifier is the element that is the most critical element to be collected uniformly. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. D.Discharged/transferred to an intermediate care facility (ICF) Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. Why such data sets are needed in the current and evolving health care arena; What multiple functions they might accomplish for a variety of different users; What data elements (including definitions, vocabularies and coding structures) they might contain; and. 28. American Hospital Association, Dawn Carlson, Ph.D. 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. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. This effort, described below, is the culmination of input from the historical knowledge and work of the Committee, including the uniform basic data sets already developed; and information provided in meetings, hearings, and through correspondence with Federal, state and local health agencies, private organizations, universities, etc. Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure. To this end, the Committee recommends that the Data Council: 3. Standard electronic formats are recommended to the extent that they have been developed. Injury Related to Employment - Yes, No. Some states and organizations are on the cutting edge of multiple use of standardized data. 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 Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. 41. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. Circulate the report within the Department for review and constructive criticism. 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. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. It will do so by assigning a unique identifier to each provider. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. Of these, approximately 70 percent provided information about their data elements. National Cancer Institute, NIH, Alfred S. Buck, M.D. Data quality is a perennial issue. 10. Office of the Assistant Secretary for Planning and Evaluation. Rural Health Advocacy Institute, Kevin Donnellan "Payers" are defined as public and private entities that have contract responsibility for health care payment. Where can the Uhdds data elements be found? The instruction clarifies that only what is known to the highest level of specificity should be reported. New York State Department of Health, Steven Davis Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. 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.) The draft systems requirement definition was issued in January, 1995. 16. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. 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. A. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? It is the expectation of the Committee that the health care field will find these recommended data elements to be fundamentally important for any collection of person and health care encounter data and will consider these elements and standardized definitions for inclusion in their data collection efforts wherever possible. A listing of all participants in the two meetings as well as those who provided written responses at any point in the process is found in appendix E. The Committee reviewed all of the input received from the hearings, meetings, letters and other communications. Birch & Davis Health Management Corporation, Inc. George F. Grob 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. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. NYLCare Health Plans, Inc. Andrew Webber Health Resources and Service Admin. Qualifier for Other Diagnoses (inpatient), 28. 4. State of Washington Department of Health, Debra C. Hopkinson, RN, MS To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. Type of Facility/Place of Encounter 1/, 19. Years of schooling has been found to be highly predictive of health status and health care use. The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. ASTM Committee E-31, Clifford P. Binder IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. Other Procedures (inpatient) - All other procedures that meet the criteria described in element 33. State of Washington Department of Health, Maria Rey Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Much of the required information can be located on the patient's face sheet. Health Care Practitioner Specialty 1/, 27. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. Health Care Financing Administration, Steven B. Cohen Facility Identification - The unique HCFA identifier as described above. American Association of Retired Persons, Peg Douglas Much of the required information can be located on the patients face sheet. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. For children under the age of 18, the mother's highest grade of schooling completed should be obtained. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. 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 . However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. 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 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. Operating Clinician Identification (inpatient), 40. What clothing brands were popular in the 50s? Where can the Uhdds data elements be found? 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). medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital. Center for Mental Health Services, Corinne Kirchner, Ph.D. 1. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. Cancer Institute, NIH, Alfred S. 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Organizations are on the patients face sheet that meet the criteria described in this section to.
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