Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. To transmit electronic data C. To create a process for transmitting data to external users D. 5. Ronald Carlson 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). 40. To this end, the Committee recommends that the Data Council: 3. Ideally, one would also collect income to more fully define socioeconomic status. 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. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. Uniform hospital discharge data set (UHDDS). 38. 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. 32. Where can the Uhdds data elements be found? Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. The following list of data elements contains those elements selected for the first iteration of this process. Health Resources and Services Administration, William E. Flynn, III ), particularly when used alone, and impediments (legal and otherwise) to its use. Managed Behavioral Health News, Melvin Sabshin, M.D. Location or Address of Encounter (outpatient) - The full address and Zip Code (nine digits preferred) for the location at which care was received from the health care practitioner of record (see 19A.). Participation in the system will be voluntary for non-HCFA providers at first. 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. At the March 1996 NCVHS meeting, many of the same standards-setting groups were present and indicated their support of the Committee's efforts. Department of Agriculture, Theresa Wulbrecht American Medical Association, Zili Sloboda, Sc.D. National Indian Council on Aging, Inc. Jacqueline R. Bennett 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. It is recommended that convergence of these guidelines be investigated. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. 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. The NCVHS recommended this as an optional item in the UACDS but that high priority should be given to conducting additional study as to the feasibility, ease and practical utility of collecting the patient's reason for encounter, in as close to the patient's words as possible. The set includes reasons for the encounter, living arrangements, and marital status. Uniform Ambulatory Care Data Set (UACDS). 02. 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. Kaiser Foundation Health Plan, Matthew McKearn Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. With the exception of the personal/unique identifier, they do not need to be collected at each encounter. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. For those data elements which have been recognized as significant core elements, but for which there is not consensus on definition, support the formation of a public-private working group to conduct or coordinate additional study or research and to further refine definitions. Their continuing study is involved with more detailed data elements that relate specifically to the areas of mental heath, substance abuse, and long term care. 14. prison), Principal diagnosis of an injury or poisoning. National Center for Health Statistics, David P. Winchester, M.D. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Provide stable resources to the project to establish an interagency work group, with DHSS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. Health Care Financial Management Association/ASC X12, Kenneth E. Roos, M.S., M.B.A. 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. State of Washington Department of Health, Maria Rey 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. Future projects may undertake to seek consensus among some of these items. Whichever method is used should be designated. Health Care Financing Administration, Steven M. Melov It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . To retrieve electronic data B. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. United States Department of Agriculture, Food and Nurtrition Service. A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. Seven confirmatory data items (including SSN) should also be collected when possible. It might not be feasible to expect the record to be updated to include payment data when it becomes available. Elliot M. Stone, M.V.C. A person currently married. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. Date of Encounter (outpatient and physician services), 18. 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. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. NYLCare Health Plans, Inc. Andrew Webber Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. 19. 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. 20. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. 26. National Center for Health Statistics. College of American Pathologists, Division of Government and Prof. Affairs. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. 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). American Nurses Association, Larry W. Miller American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. Expected insurance payer number or code. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. Computer Network Architects, Inc. Barry Gordon National Academy for State Health Policy, Marie Roberto, Dr.P.H. With relatives other than spouse, children, or parents, Residence where health, disability, or aging related services or supervision are available, Other residential setting where no services are provided, Other institutional setting (e.g. The .gov means its official. Current or Most Recent Occupation and Industry 2/, 16. * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. UHDDS Today Hospital or facility identification number or code. The personal/unique identifier is the element that is the most critical element to be collected uniformly. University System of West Virginia, Curtis O. Porter Race and ethnicity 04a. Grouping of similar services provided on different dates, as is often the case under batch billing, can be problematic if specificity of data elements is lost; the objective is to encourage identifying a unique date of record for each encounter. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. 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. and is the best alternative to insure the availability of small area data. For example, the State of California, in testimony to the NCVHS, described its efforts in improving health and health care delivery by linking data collected through medical facilities, school-based health and educational data bases, as well as need-based data bases such as eligibility listings for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) or reduced school-lunch programs. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. It will also serve as a quality check as the date of birth approaches the new century mark. Currently there is little or no input from the public health field for several reasons. University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell Some recommendations in the area of mental health and substance abuse are included here. The NPI/NPF will provide a common means of uniquely identifying health care providers, including institutions, individuals, and group practices, both Medicare providers and those in other programs. Sufficient penalties for breach of confidentiality either do not exist or are not enforced. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. Larry Deutsch, M.D., M.P.H. 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. 16. Problem, Diagnosis or Assessment (outpatient). DCPC/NCCDPHP/CDC, Raymond C. Zastrow 29. The Committee has recognized that data confidentiality is a major concern in the collection of health data from an increasing number of sites, and the Committee has long been concerned with personal privacy and data confidentiality issues. Which of the following data elements is unique to Uhdds quizlet? Of 18 trade or professional associations contacted, only four submitted data sets. 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. The National Committee on Vital and Health Statistics (NCVHS) and the Department of Health and Human Services, which it advises, have initiated and completed the first iteration of a process to identify a set of core health data elements on persons and encounters or events that can serve multiple purposes and would benefit from standardization. National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS In a number of instances, lists of data items were obtained, but without definitions. Data elements used in UACDS are provider Identifications, address, type of practice, which includes the full name of the provider as well as the unique physician identification number (UPIN). American Hospital Association, Edward W. Bacon What potential problems, such as assuring data quality and preserving confidentiality of identifiable records, can be expected and what approaches might be used to address these problems. 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.). The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. Rural Health Advocacy Institute, Kevin Donnellan As recommended by the UACDS, address should be in sufficient detail (street name and number, city or town, county, State, and Zip Code) to allow for the computation of county and metropolitan statistical area. Date of Encounter (outpatient and physician services) - Year, month, and day of encounter, visit, or other health care encounter, as recommended by the UACDS and ANSI ASC X12. National Center for Health Statistics, Barbara D. Matula The Committee recommends that the HCFA identifier be adopted when completed. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. Core Health Data Elements Project No decisions have been made by the Department on any of these recommended revisions of either the UHDDS or the UACDS. Health Care Financing Administration, Steven B. Cohen The currently recommended coding instrument is the ICD-9-CM. Marital Status - The following definitions, as recommended by the NCVHS, should be used. What is the essential clinical dataset? The Subcommittee determined that residential street address has the advantage of enabling researchers to aggregate the data to any level of geographic detail (block, census tract, ZIP code, county, etc.) However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. Circulate the report within the Department for review and constructive criticism. Those present at the November and December 1995 NCVHS regional meetings agreed that the establishment of a unique identifier is the most important core data item. National Institute of Dental Research, NIH, T. J. Mathews This has resulted in inconsistent data found in many outpatient databases and has skewed patient outcome studies. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. Performance monitoring and outcomes research are two additional areas that are currently hampered by the inability to link data sets from various sources due to varying data elements and definitions. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. American Association of Retired Persons, Peg Douglas National Committee for Quality Assurance, James S. Todd, M.D. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. New York State Department of Health, Steven Davis Assistant Secretary for Planning and Evaluation, Room 415F Concurrent with these activities being undertaken by the full Committee, there are two related projects undertaken by the Subcommittee on Mental Health Statistics and the Subcommittee on Disability and Long Term Care Statistics. Include the full name of the provider as well as the National Provider. However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter. 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. 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Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Gender As recommended by the UHDDS and the UACDS. The site is secure. Additionally, too frequent modification of items or definitions will cause confusion, overlapping data definitions in a single data year, and add to the burden of the facility or organization. Race and ethnicity B. 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. Additionally, includes optional data elements to describe the patients living arrangements and marital status. Office of Inspector General. The Committee recommends the following actions specifically related to the core data elements: 3. Periodicity of assessment also is an issue. 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. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. It is recommended that the year of birth be reported in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. Updates of activities in each of the agencies are presented to the Committee on a regular basis. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. Birch & Davis Health Management Corporation, Inc. George F. Grob 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. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. 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. Therefore, billed charges should be collected, at a minimum. The currently recommended coding instrument is the ICD- 9-CM. Date of Birth Month, day, and year of birth. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. No EP studies. Other recommendations will be circulated for comment at a future time. Although the UHDDS has been in the field for two decades and its data items are widely used by government and private organizations, issues of quality and comparability remain. New Hampshire Division of Public Health Service, Robert Roscoe 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. UACDS and UHDDS have many similar data elements, which makes it easier to. A person who has never been married or whose only marriages have been annulled. This group, or a separate group, could also be the focus for evaluating additions to the list of core data elements and for setting up methods for testing and promulgating the final products. In addition, the Committee and Department have been involved in activities related to standardizing the collection of data in the long-term care setting. 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. A presentation by AHCPR reported on a study of 10 state data organizations and two statewide hospital associations participating in the Healthcare Cost and Utilization Project (HCUP-3). California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Condition(s) should be recorded to the highest documented level of specificity. Centers for Disease Control and Prevention, Lynn E. Jensen, Ph.D. ASTM Committee E-31, Clifford P. Binder every facility where ambulatory care is delivered. Georgia State University, Maria Redona Couper The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. The National Association of Health Data Organizations has also opposed such an inclusion. Location or Address of Encounter (outpatient), 21. The MEDSTAT Group, Joel Diringer, JD. 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