Health Level 7 Ernst & Young LLP, Jerri Regan Respondents have indicated a mixed use of this item for inpatients. It will also serve as a quality check as the date of birth approaches the new century mark. 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. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. However, there is some evidence that the number of interracial marriages is accelerating. Catherine McCabe E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution Recommendations and linkage with the current project will be discussed. Current or Most Recent Occupation and Industry - This data item is very useful to track occupational diseases as well as to better define socioeconomic status. 17. F.Discharged/transferred to home under care of organized home health service organization 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. Much of the required information can be located on the patients face sheet. ASTM (American Society for Testing and Materials ). In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. 33. These elements are unique to the UACDS. B.Spouse Information is collected by a wide range of users and in a myriad of different formats. 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. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . Uniform hospital discharge data set (UHDDS). It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. 28-31. Place the Committee's report, elements and definitions on an appropriate departmental Home Page as guidance to the field and as a means of encouraging use and soliciting further comments and suggestions while the report is under review within the Department. Oak Orchard Community Health Center, Geraldine Nicholson Sex Male or female 04. 36. Current or Most Recent Occupation and Industry, 28. Gender As recommended by the UHDDS and the UACDS. . NUBC (National Uniform Billing Committee), NUCC (National Uniform Claim Committee), and. 4. National Association Children's Hospitals, George Arges 20. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Vermont Health Care Authority, Michael G. Kassis These activities could take several forms. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. Capture of the full four-digit year of birth is recommended 03. The UACDS is a recommended set, not a mandatory one. Provider Location or Address of Encounter (outpatient), 22. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). 3. 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. Circulate the report within the Department for review and constructive criticism. What clinical information is collected in the Uhdds? Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. Michael L. Glickman Health Care Financing Administration, David L. Hobson Which data is collected on Medicare and Medicaid patients? 5. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. White, M.P.H., Ph.D. Congress of the United States, Emilie Schmeidler, Ph.D. 20. The instruction clarifies that only what is known to the highest level of specificity should be reported. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. 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. A total of 31 responses were received. 6. D'Angelo, B.S., M.S. 25. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. From the respondents, a total of 138 different data elements were obtained. ICD-10-PCS code for: 1. The MEDSTAT Group, Joel Diringer, JD. Illinois Department of Public Aid, Amanda Attridge Henson Where can the Uhdds data elements be found? American Nurses Association, Larry W. Miller Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. 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. The Alan Guttmacher Institute, Kathleen A. Frawley 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. 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); ANSI (American National Standards Institute). Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. Patient's Stated Reason for Visit or Chief Complaint (outpatient) - Includes the patient's stated reason at the time of the encounter for seeking attention or care. Interregional Services, James P. Cooney, Jr., Ph.D. Deborah Lieberman, MHSA, OTR/L, PAOTA Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. 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Children's Memorial Hospital, Ernest J. Sessa For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 1. This term is one that needs study and evaluation before it can be implemented. Of these, approximately 70 percent provided information about their data elements. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). offices, the location of the usual or principal place of practice should be given. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. The set includes reasons for the encounter, living arrangements, and marital status. 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 Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. But time is short; decisions are being made by organizations now. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. American Medical Association, Cary Sennett, MD, Ph.D. 200 Independence Avenue, SW In accepting these challenges, the Committee seeks to facilitate consensus development and incorporate the concepts of multiple use, continued change, and long-term evolution of core data elements into general thinking and practice. 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. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. Don L. Zimmerman, Ph.D. 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. 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. 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. What are the Root Operations? The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. 31. Standards groups should be consulted regarding setting criteria for recording of names. 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. Center for Mental Health Services, Corinne Kirchner, Ph.D. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. New York, using the last 4 digits of the Social Security Number, with other characteristics (such as date of birth), indicated a match rate exceeding 99 percent. Medicare decided a PAYERID was needed because of the difficulty its contractors were having in transferring claims to other insurance companies, due to incomplete information or multiple names for payers. Race and ethnicity B. Principal Diagnosis (inpatient) - As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. Patient's Expected Sources of Payment 1/. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. A. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. Paul Y. Ertel, M.D. American Public Health Association, Linda Vader, RN, CRNO Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. Expected insurance payer number or code. 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. and is the best alternative to insure the availability of small area data. The currently recommended coding instrument is the ICD-9-CM. Uniform hospital discharge data set For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Operating Clinician identification 1/. The set is used to collect demographic and clinical data on nursing home residents that must be completed for every resident at the time of admission and during reassessment periods. American Health Information Management Association, Louis I. Freedman Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. ICD-9-CM Vol. Primary Diagnosis (inpatient) - The diagnosis that is responsible for the majority of the care given to the patient or resources used in the care of the patient. 14. 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. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. 34. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. A significant procedure is one that is: Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. UACDS differs from UHDDS with data elements specific to ambulatory . Location or Address of Encounter (outpatient), 21. Future projects may undertake to seek consensus among some of these items. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. In the early 1990's, it formed an Ad Hoc Work Group on Confidentiality to study issues related to confidentiality, unique personal identifiers and data linkage across time and systems. 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