Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. It is recommended that convergence of these guidelines be investigated. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. 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). Particular scales are more appropriate for measuring different functions or disabilities and should be selected on the basis of the needs of the patient population (such as, use of social functioning scales for those with mental disorders and substance abuse). 38. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. Paul Y. Ertel, M.D. UACDS and UHDDS have many similar data elements, which makes it easier to. 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. 28. 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. MPH Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. Some of these included 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, to mention a few. 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. 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. 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) Injury Related to Employment - Yes, No. https://www.health-improve.org/what-is-uacds-in-healthcare/ 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. 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. American Hospital Association, Dawn Carlson, Ph.D. 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. Carries a procedural risk, or. Association of Maternal and Child Health Programs, Karl S. Finison The ICD-9-CM is the recommended coding convention. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. FACEP and provide a thorough description of what you have chosen. 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. American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. 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. 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. 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. For those elements that the Committee recommends as being ready to standardize, request each of the data collection entities within the Department to review the set of data elements and to match data contents and definitions with similar items that they are currently collecting or plan to collect. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. 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). Ronald Carlson B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. 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. In the future, the system will integrate non-HCFA subscribers. Centers for Disease Control and Prevention. A commonly used measure is the person's rating of his or her own general health, as in the five-category classification, "excellent, very good, good, fair, or poor." 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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. 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. 10. ANSI HISPP (Health Informatics Standards Planning Panel). An official website of the United States government. American Physical Therapy Association, Anthony J. NCQA - National Committee for Quality Assurance, Yvonne Senturia, M.D., M.Sc. 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. College of American Pathologists, Division of Government and Prof. Affairs. To transmit electronic data C. To create a process for transmitting data to external users D. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. Michigan Department of Social Services, Interagency Coordination Program, Stephen W. Wyatt, D.M.D., M.P.H. University of California. The Commonwealth of Massachusetts, Rate Setting Commision, Daniel J. Friedman, Ph.D. New York State presented testimony that indicated that the last four digits of the SSN combined with the birth date were capable of linking data to a very high degree of probability. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock American Medical Association, Herbert G. Traxler, Ph.D. Center for Mental Health Services, Corinne Kirchner, Ph.D. ICD-9-CM Vol. It became obvious that staff dedicated to participating in and monitoring the activities of these organizations is crucial if all relevant voices (including public health and epidemiology) are to be heard. The American Academy of Family Physicians, Barbara Faigin Future projects may undertake to seek consensus among some of these items. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. National Indian Council on Aging, Inc. Jacqueline R. Bennett In addition, information was solicited by the NCVHS through two large-scale mailings, and public meetings were held with agencies and organizations which are currently collecting health data sets. American Association of Retired Persons, Peg Douglas Health Resources and Services Administration, William E. Flynn, III This term is one that needs study and evaluation before it can be implemented. Department of Veterans Affairs, Assistant Secretary for Policy and Planning, Mary Dufour Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. Standardized coding schemes, such as the Census Bureau's Alphabetical Listing of Occupation and Industry and the Standardized Occupation and Industry Coding (SOIC) software developed by the National Institute for Occupational Safety and Health, should be reviewed. Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. Type of Facility/Place of Encounter. Of these, approximately 70 percent provided information about their data elements. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. IM System, David Newman, M.D. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. 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. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. The database will contain payer names, billing addresses and business information. Problems could arise from adding and modifying data items and definitions too frequently. Which of the following data elements is unique to UACDS A. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. Race and ethnicity B. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA State of Kansas Department of Health and Evironment, Renate E. Pore National Center for Health Statistics, Barbara D. Matula HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Also in March, a consultant to the NCVHS updated the World Health Organization on the core data element activity and returned with input to the process. It is possible that the description of functional status may entail more than a single measure, thus needing space for more than one measure and/or an additional element to document the scale used. A chart showing the distribution of all respondents by type of organization is shown in appendix D. Approximately 30 percent of respondents were from state and local governments, followed by professional associations and the Federal Government with 18 Percent and 17 percent respectively. 5. National Institute on Drug Abuse, Cille Kennedy Development of a unique identifier does not necessarily mean that the individual is identifiable to users. "Payers" are defined as public and private entities that have contract responsibility for health care payment. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. However, recent testimony has led the Committee to investigate this issue further, in light of perceived inadequacies of the SSN (e.g., lack of a check digit, multiple SSN's, etc. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. 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. D'Angelo, B.S., M.S. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. National Center for Health Statistics, Richard Rubin The UACDS is a recommended set, not a mandatory one. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka 02. Legal Services of Middle Tennessee, Leonard Bourget 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. 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. 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. They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. 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. Some third party payers, however, have ignored the guidelines and required facilities and health care practitioners to report a diagnosis that justifies the performance of services being provided. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. Problem, Diagnosis or Assessment (outpatient). 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. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional study and evaluation must be undertaken to reach consensus on standardized content and definition. G.Discharged/transferred to home under care of a Home IV provider In 1989, NCVHS approved the UACDS, recommending its use in. Thomas P. Gross, M.D., MPH As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes 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. Permanente Medical Group 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. National Association of Health Data Organizations. Illinois Department of Public Health, Frank C. Lemus 23. 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. Zwerling, M.D., Ph.D will allow the application of GIS ( Geographic Systems. 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