Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. 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. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. every facility where ambulatory care is delivered. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. 40. The Committee recognizes that not all providers are obtaining this detail, but it is anticipated that these data will be more frequently collected in the near future with the growth of computerized prescription information. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka 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. 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. 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. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. The UACDS is a recommended set, not a mandatory one. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan . Association of State and Territorial Health Officials, D. Walter Biggs, III New Hampshire Division of Public Health Service, Robert Roscoe Uniform Ambulatory Care Data Set. 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. 1. The personal/unique identifier is the element that is the most critical element to be collected uniformly. Social Security Administration, Andrew A. But time is short; decisions are being made by organizations now. Principal diagnosis is required by most systems for inpatient reporting. Although 61 requests were made regarding data sets, almost one-third of respondents indicated that they did not have a set of health data items that they collected. H.Left against medical advice or discontinued care. Problems could arise from adding and modifying data items and definitions too frequently. Currently there is little or no input from the public health field for several reasons. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Attending Physician Identification (inpatient), 22. At the very minimum, there need to be "place holders" provided to standards organizations to inform them that certain data elements are critical elements, even when the specific format of the items is currently undecided. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. Deborah Lieberman, MHSA, OTR/L, PAOTA 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. HBO and Company. A. Health Insurance Association of America, John I. Gallin, M.D. In some instances, lists of items were received with many basic data items not included. 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.). ANSI HISPP (Health Informatics Standards Planning Panel). 18. No decisions have been made by the Department on any of these recommended revisions of either the UHDDS or the UACDS. D.Discharged/transferred to an intermediate care facility (ICF) The UACDS is a recommended set, not a mandatory one. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. Living/Residential Arrangement - The following definitions are recommended by the NCVHS: Multiple responses to this item are possible. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. A. What are the Root Operations? Years of Schooling - Highest grade of schooling completed by the enrollee/patient. There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. Operating Clinician Identification (inpatient), 40. Rural Health Advocacy Institute, Kevin Donnellan Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. The response to the Committee's activities both through participation in meetings and written comments indicates that the health care information field is solidly in favor of the identification and use of standardized data elements and definitions. To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. Multiple responses are possible. There is less agreement on data definitions, even for data items that have been in the field for years. Centers for Disease Control and Prevention. 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. Ideally, one would also collect income to more fully define socioeconomic status. National Organization of urse Practitioner Faculties, Peter M. Wheeler For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. Throughout the meetings it became apparent that many standards-setting groups are moving ahead without broader input, for example, from those in the public health and epidemiology fields. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). MPH Although there is agreement that "payments" or "costs" are needed, most participants agreed that it is virtually impossible to collect these items consistently across time and locations. Kaiser Permanente, Medical Economics, Kathleen H. Fyffe 12. 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). 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. I need the ICD-10-PCS codes 2. Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich 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. 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. Department of Public Health, Dan Rode UACDS and UHDDS have many similar data elements, which makes it easier to. Phillippine Nurses Association of America, Karen Grady 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. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. Shortly after arrival in the ER, the patient's. 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. To this end, the Committee has advised the Department on such matters as Federal-state relationships, nomenclatures and classification systems, core data sets, and access and confidentiality issues. 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. A unique identifier such as the SSN in conjunction with at least one other data item or, alternatively, an identifier drawn from another distinct set of data items routinely collected presently would seem the most viable. Four digits are recommended for the discharge year. Date of Encounter (outpatient and physician services), 18. Expected insurance payer number or code. UACDS Data Elements Data Element Definition/Descriptor Provider identification, address, type of practice Place of encounter Reason for encounter Diagnostic services Problem, diagnosis, or assessment Therapeutic services Preventive services Disposition Provider identification: Include the full name of the provider as well as the National Provider Identifier (NPI). However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. Kaiser Foundation Health Plan, Matthew McKearn It also includes other data elements such as Place of encounter to specify locations, reason for encounter that outlines the patient complaints and symptoms reflecting their own perceptions of needs, and diagnostic service that give a description of all types of service. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. The transference of data sets from the traditional sources has not fully met the needs of these sites. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Data quality is a perennial issue. American Nurses Association, Larry W. Miller Standardized data sets can serve many purposes in the current and future health care arena. 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. State of Washington Department of Health, Debra C. Hopkinson, RN, MS National Center for Health Statistics, David P. Winchester, M.D. 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. 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. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. Current or Most Recent Occupation and Industry 2/, 16. 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. 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. 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 will do so by assigning a unique identifier to each provider. 5. 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. The following list of data elements contains those elements selected for the first iteration of this process. Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. Condition(s) should be recorded to the highest documented level of specificity. Oak Orchard Community Health Center, Geraldine Nicholson State of Texas Department of Health, Mike McGinty, Ph.D. And now, with movement toward HMO's, PPO's, and other types of managed care, there may be a greater need to share identifiable data. Other recommendations will be circulated for comment at a future time. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. American Public Health Association, Linda Vader, RN, CRNO 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. Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. UHDDS vs NCVHS Core Health Data Elements.docx, Neehr Perfect EHR Activity-UHDDS and the EHR v7.docx, CHAPTER 10- CPT EVALUATION AND MANAGEMENT.docx, HIMT 101 Chapter 3 Review Questions (2).docx, Chapter 6 Medical billing and coding.docx, Use the Boston Matrix to decide which products warrant further investment and, AFIQAH ZAHIDAH BINTI ANWARZAINI_2017739723_GLS680.pdf, What is the function of the BHE signal in 8086 BHE signal means Bus High Enable, i A D B means A is mother of B ii A B means A is sister of B iii A B means A is, Lisa Rocks Ltd Lisa Rocks Ltd manufactures landscaping equipment Below is an, 4 Which one of the following is not an employee advantage associated with the, A heat exchanger to preheat oil for a furnace was designed without considering, The broad outline of the provenance of The Ambassadors is known It is presumed, PRL Di Salvo Syllabus (Fall 2022 Section 12) - Copy.pdf, and actin myosin rather than through direct increase of intracellular calcium, 9 Which of the following player scored a hattrick during their Manchester United. National Institute of Occupational Safety and Health, Stewart H. Streimer As recommended by the UHDDS and the UACDS. Include the full name of the provider as well as the National Provider. Total Billed Charges - All charges for procedures and services rendered to the patient during a hospitalization or encounter. 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. American Occupational Therapy Association, Kitty Werner Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. 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. 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. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. 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. Date of Birth Month, day, and year of birth. 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. 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 [] Minnesota Department of Health, Trish Riley 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. HHS, HCFA, Office of Managed Care, Gordon Bonnyman Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. A. Health Care Practitioner Identification (outpatient) 1/, 20. Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. Location or Address of Encounter (outpatient), 21. The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Patient's Stated Reason for Visit or Chief Complaint (outpatient). Managed Behavioral Health News, Melvin Sabshin, M.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. It will also serve as a quality check as the date of birth approaches the new century mark. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. 2. U.S. Department of Health and Human Services compare data for inpatients and ambulatory patients in the same or among other facilities. The Committee's intent is not to specify a data set for mandated external reporting; not every element may be needed in a specific collection effort, and these data elements do not represent all of the important data items that are collected in the field or needed for specific applications. St. Peter's Community Hospital, Ron Horner, Ph.D. University of California. A lack of footnote indicates that the element is ready for implementation. To retrieve electronic data B. Which data is collected on Medicare and Medicaid patients? Core Health Data Elements Project Office of the Assistant Secretary for Planning and Evaluation. Race and ethnicity 04a. 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. 3. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. American Hospital Association, Dawn Carlson, Ph.D. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. 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." Applied Medical Data, Inc. Kenneth L. Evans, M.D. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). In a nutshell, the ECD defines the data elements that are essential to be documented for a patient within the EHR so the care team may provide quality care. Uniform Ambulatory Care Data Set. Uniform Ambulatory Care Data Set (UACDS). Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. This element refers to living arrangements only. Periodicity of assessment also is an issue. 10. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. The description of the element indicates this present lack of agreement. 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. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. NCQA (National Committee for Quality Assurance). 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.