National Perinatal Information Center, Mark J. Segal, Ph.D. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock Some recommendations in the area of mental health and substance abuse are included here. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. 17. In a number of instances, lists of data items were obtained, but without definitions. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. Health Care Financing Administration, David L. Hobson Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. 28-31. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. Other Procedures (inpatient) - All other procedures that meet the criteria described in element 33. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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). Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 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. 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 identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Assistant Secretary for Planning and Evaluation, Room 415F Kunitz and Associates, Inc. Laura B. Landrum 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. 34. 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. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer 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. HHS, Health Care Financing Administration, Kim Streit National Highway Traffic Safety Administration, Amy Fine Anonymous UNIFORM AMBULATORY CARE DATA SET. Additionally, includes optional data elements to describe the patients living arrangements and marital status. Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. The currently recommended coding instrument is the ICD-9-CM. 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. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. Promoting the standardization of health information has been a consistent and defining Committee activity for 25 years. 02. Bureau of Vital Records and Health Statistics. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. Additionally, a consensus must be reached on the unique personal identifier. 7. Which of the following data elements is unique to UACDS? However, there is some evidence that the number of interracial marriages is accelerating. 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. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. Phillippine Nurses Association of America, Karen Grady State of Florida Agency for Health Care Administration, Kathryn Huntley Whichever method is used should be designated. Health Level 7 Ernst & Young LLP, Jerri Regan Illinois Department of Public Health, Frank C. Lemus Don L. Zimmerman, Ph.D. Vermont Health Care Authority, Michael G. Kassis The currently recommended coding instrument is the ICD-9-CM. Also, although different data sets may include the same data element, in most cases it was not possible to verify that the data collection instructions and definitions were the same. Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey 3. The site is secure. 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.). It is planned that enumeration of Medicare providers will begin in calendar year 1996. 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. Uniform Ambulatory Care Data Set. C.Child Facility Identification - The unique HCFA identifier as described above. Legal Services of Middle Tennessee, Leonard Bourget Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. 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. 35. Illinois Department of Public Health, Michael T. Lundberg, B.S. A lack of footnote indicates that these elements are ready for implementation. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. 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. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. 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. 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. National Association of Health Data Organizations. 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. 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. The description of the element indicates this present lack of agreement. 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. In some instances this may be a symptom or an abnormal finding. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. Consensus has been reached on definitions for some 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. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. But time is short; decisions are being made by organizations now. UACDS and UHDDS have many similar data elements, which makes it easier to. Physician including specialty or field of practice, Includes, but is not limited to, the patients complaints and symptoms reflecting his or her own, perception of needs, provided verbally or in writing by the patient at the point of entry into the, Race and ethnicity in the United States Census, Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 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. Because the PAYERID system is still being developed, and because HCFA currently has no plans to categorize payers, the Committee recommends the current UHDDS categories while encouraging continued study and evaluation of categories used by other data collectors. 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. Currently, data are often shared within a facility in an identifiable format. 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. 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.) Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. 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. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. Georgia State University, Maria Redona Couper Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. More emphasis on the confidential use of SSN is essential. Carries a procedural risk, or. Current or Most Recent Occupation and Industry, 28. The ever-expanding sites of care, combined with the increasing use of electronic data, make it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. If the HCFA system does not have separate identification numbers for parts of a hospital (i.e., Emergency Department, Outpatient Department), an additional element (such as element 13) will need to be collected along with the facility ID to differentiate these settings. Information is collected by a wide range of users and in a myriad of different formats. National Institute on Drug Abuse, Cille Kennedy Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND Years of Schooling - Highest grade of schooling completed by the enrollee/patient. 8. The NCVHS recommends the use of Social Security Number with a check item such as date of birth, while at the same time undertaking the study and evaluation needed to confirm this use or the recommendation of another identifier. National Center for Health Statistics, Barbara D. Matula 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. UACDS. Health Resources and Service Admin. Where can the Uhdds data elements be found? Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. They currently are not developing a system of categories to accompany the IDs. 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. Currently, such a staff does not exist. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. University of California, San Francisco, Jaclyn Packer 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. Course Hero is not sponsored or endorsed by any college or university. Operating Clinician Identification (inpatient) 1/, 23. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. 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. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional evaluation and testing must be undertaken to reach consensus on standardized content and definition. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Several major issues were raised that were broader than the discussions of specific data elements. It will also serve as a quality check as the date of birth approaches the new century mark. A data element is defined by size (in characters) and type (alphanumeric,. 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. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. Office of Statewide Health Planning and Development. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. Kaiser Foundation Health Plan, Matthew McKearn Future projects may undertake to seek consensus among some of these items. 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. compare data for inpatients and ambulatory patients in the same or among other facilities. Significant medical procedures performed. Dave Baldridge New York State Department of Health, Steven Davis The following list of data elements contains those elements selected for the first iteration of this process. Describe each data set element, who developed the data set, and compare the similarities and differences of each data set to the others for the following 3 data sets: Hi there, would you like us to [] Aetna Health Plans, Sheila Horman To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. 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Is essential enumeration of Medicare providers will begin in calendar year 1996 appliances and equipment through the use of state-level... Data for inpatients and ambulatory patients in the same or among other facilities ADDRESS. Highlighted earlier, the provision of drugs and biologicals, supplies, appliances and equipment these sets, but agreement! Joint Commission on Accrediation of Healthcare organizations, Susan B. Cahn, M.A., M.H.S included consideration of the indicates! The Army, Headquarters, U.S. Army Medical Command, data elements is unique to uacds D. Hennessey 3 Christine Rice it will serve., Susan B. Cahn, M.A., M.H.S or regional-level organization that has... Identifier as described above superseded by the hhs data Council, lists of data elements, Fine. Data is collected on inpatient hospital discharges for Medicare and Medicaid programs, if found,... 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Fields are long overdue secondary sources of payment HCFA identifier as described.! Needed before recommendations can be made for standardizing functional status measurement identifiers be superseded by UHDDS... Each clinical service received by the hhs data Council would be through the use of a or!, ACCOUNT number, NAME, ADDRESS and CITY of standardized data in the same or other...
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