The American Academy of Family Physicians, Barbara Faigin Capture of the full four-digit year of birth is recommended 03. 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. In August 1994, the Department recognized the National Committee's unique history in promoting standardization of health information when it 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. Assistant Secretary for Planning and Evaluation, Room 415F The NCVHS notes that the Department of Veterans Affairs routinely collects this element, and thus approves the continued inclusion in this core list, pending a review of uses and users of this element. It will do so by assigning a unique identifier to each provider. National Institute of Occupational Safety and Health, Stewart H. Streimer It is anticipated that the introduction of ICD-10 will alleviate this problem. To retrieve electronic data B. 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. Condition(s) should be recorded to the highest documented level of specificity. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . Marital Status - The following definitions, as recommended by the NCVHS, should be used. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. ANSI HISPP (Health Informatics Standards Planning Panel). To identify the large number of organizations involved in various aspects of health data standards, staff at NCHS produced a report (see appendix H) describing the various groups by type of organization. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. 2. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. 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. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. 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. A lack of footnote indicates that these elements are ready for implementation. Classify common law marriage as married. 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. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.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. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. At the present time, standards- setting organizations should assign place holder(s) for this element. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. 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. 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. 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. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. National Committee for Quality Assurance, James S. Todd, M.D. HRSA, Bureau of Primary Care, Mary Reister Data quality is a perennial issue. 31. Association of Maternal and Child Health Programs, Karl S. Finison Type of Facility/Place of Encounter 1/, 19. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Core Health Data Elements Project Provider Location or Address of Encounter (outpatient), 22. At present, there is no widely recognized instrument for measuring the functional status of children. 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. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. The type of data collected in each different facility's patient health records is established by required standards or regulations. 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. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. 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. Qualifier for Other Diagnoses (inpatient), 28. 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. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. Health Level 7 Ernst & Young LLP, Jerri Regan These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. No EP studies. The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. 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. 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A person who has never been married or whose only marriages have been annulled. Illinois Department of Public Health, Frank C. Lemus Paul L. Grimaldi, Ph.D. Health Resources and Service Admin. 23. 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. APHA American Public Health Association, Katherine M. McCormack Response was significant and positive to the Committee's request to review a set of core data elements that were identified after a series of hearings and other information- gathering efforts were completed. 38. These include the review and implementation of core data elements and definitions within departmental data collection activities; formation of public-private work groups to assist in promulgating data elements for which consensus has been reached or for undertaking additional study on critical elements for which there are no standardized definitions. Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. It will also serve as a quality check as the date of birth approaches the new century mark. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. 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. H.Left against medical advice or discontinued care. Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. 12. State of Washington Department of Health, Debra C. Hopkinson, RN, MS 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. Source of payment categories, as recommended in the past, are no longer sufficient. National Academy for State Health Policy, Marie Roberto, Dr.P.H. Michael L. Glickman 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. The Committee recommends that the HHS Data Council: 2. The currently recommended coding instrument is the ICD-9-CM. American Association of Retired Persons, Peg Douglas A number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). Race and ethnicity B. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. University of California, San Francisco, Jaclyn Packer NYLCare Health Plans, Inc. Andrew Webber Which of the following data elements is unique to UACDS A. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. Participation is voluntary, and HCFA, which is funding its development, has been working to get consensus about the kind of system that would be useful. 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. But time is short; decisions are being made by organizations now. 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. Disposition of Patient (inpatient) 1/, 40. 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). Patient's Stated Reason for Visit or Chief Complaint (outpatient). Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. Shortly after arrival in the ER, the patient's. However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. 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. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. National Association of Health Data Organizations. Health Care Practitioner Identification (outpatient) 1/, 20. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. St. Peter's Community Hospital, Ron Horner, Ph.D. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. The immediate goal of the NPI/NPF project is to support HCFA's Medicare Transaction System initiative by providing a single, universal method for enumerating the providers who serve Medicare beneficiaries. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. State of New Jersey Department of Health, Dennis Duffy Additional evaluation and testing are needed on standardizing the health status element. HCFA is developing a new system, called the HCFA PAYERID project, which will assign a unique identifier to every payer of health care claims in the United States. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. It is important to note for this report, however, that the two subcommittees are in agreement with the core data elements that are described herein. 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. Confidentiality of identifiable records is another critical issue. Work on this topic is currently ongoing in the NCVHS Disability and Long-Term Care Statistics Subcommittee. Significant medical procedures performed. 5. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. BlueCross BlueShield of Minnesota. Providers, Insurers, and universities represented about 7 percent each. 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. Who will have access to the database for research purposes, and to what data, has yet to be determined. 33. Sex Male or female 04. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. U.S. Department of Health and Human Services 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). Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. National Institute on Drug Abuse, Cille Kennedy What clinical information is collected in the Uhdds? ASTM Committee E-31, Clifford P. Binder It is of vital importance to participate in and/or be members of the numerous data standards groups. A large number were collected by only a few of the data sets. Include the full name of the provider as well as the National Provider. 21. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. 28-31. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). It is planned that enumeration of Medicare providers will begin in calendar year 1996. Health Care Practitioner Identification (outpatient), 21. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. Marital status is discussed in element 6. 35. University of California--San Francisco, Marlene M. Lugg Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Alexis A. Wilson Course Hero is not sponsored or endorsed by any college or university. Maine Health Care Finance Commission, Harriet Starr Which of the following data elements is unique to UACDS? Permanente Medical Group 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. Ronald Carlson The complete address of the providers office. 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 the Assistant Secretary for Planning and Evaluation. 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. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. 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. Ideally, one would also collect income to more fully define socioeconomic status. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Health Insurance Association of America, John I. Gallin, M.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. 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. The National Provider Identifier and National Provider File (NPI/NPF), currently under development by the Health Care Financing Administration (HCFA) and intended for implementation in 1997, could and should meet this need, if all providers are included. In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. In some situations, it is possible that a free-form narrative will be collected in place of the codes, to be coded at a later point. 42. 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. 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