Federal government websites often end in .gov or .mil. Seven confirmatory data items (including SSN) should also be collected when possible. A lack of footnote indicates that these elements are ready for implementation. 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. D.Discharged/transferred to an intermediate care facility (ICF) 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 Hospital Association, Dawn Carlson, Ph.D. American Medical Association, Zili Sloboda, Sc.D. An official website of the United States government. However, identifiers are commonly removed when a data set is provided outside of a facility, such as to a state health data organization. Deborah Lieberman, MHSA, OTR/L, PAOTA It is important to note for this report, however, that the two subcommittees are in agreement with the core data elements that are described herein. Ideally, one would also collect income to more fully define socioeconomic status. Include the full name of the provider as well as the National Provider. Additionally, a consensus must be reached on the unique personal identifier. Core Health Data Elements Project If you continue to use this site we will assume that you are happy with it. Operating Clinician Identification (inpatient) 1/, 23. To this end, the Committee recommends that the Data Council: 3. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. Washington, D.C. 20201, U.S. Department of Health and Human Services, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Collaborations, Committees, and Advisory Groups, Physician-Focused Payment Model Technical Advisory Committee (PTAC), OS-Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, Core Health Data Elements: Report of the National Committee on Vital and Health Statistics. Personal Identification 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. The Committee encourages the use of the above definition, while continuing to study and evaluate other residential categories, such as those used by the Bureau of the Census. 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. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. It became obvious early in the meetings that the identification of core data elements, their definitions, and the consensus-building needed to encourage use of these items would be an ongoing and full-time activity for several years. New York State Office of Mental Health, James T. Howell, MD What clinical information is collected in the Uhdds? Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. It will also serve as a quality check as the date of birth approaches the new century mark. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. Office of Statewide Health Planning and Development. 31. 200 Independence Avenue, SW National Institute of Dental Research, NIH, T. J. Mathews DCPC/NCCDPHP/CDC, Raymond C. Zastrow 25. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. National Perinatal Information Center, Mark J. Segal, Ph.D. More emphasis on the confidential use of SSN is essential. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. He had visited a number of western European countries speaking with experts in health information infrastructure, and reported that several countries now have a national policy of support for the computerized patient record. The UACDS is a recommended set, not a mandatory one. Date of Encounter (outpatient and physician services), 18. Paul Y. Ertel, M.D. One major reason is the staff and dollar resources required to travel to and participate in several meetings per group per year. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. Four digits are recommended for the discharge year. Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. Congress of the United States, Emilie Schmeidler, Ph.D. Applied Medical Data, Inc. Kenneth L. Evans, M.D. American Foundation for the Blind, Karen Kmetik 4. The type of data collected in each different facility's patient health records is established by required standards or regulations. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution UHDDS Today Hospital or facility identification number or code. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. 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. During the October 1995 and March 1996 NCVHS meetings, Dr. Don Detmer, University of Virginia, updated the Committee on international progress in data standardization and computerized patient records. What does ambulatory care include? Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. Race and ethnicity B. NYLCare Health Plans, Inc. Eugene Stanton Currently there is little or no input from the public health field for several reasons. It is recommended that convergence of these guidelines be investigated. United States Department of Agriculture, Food and Nurtrition Service. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. Consensus has been reached on definitions for the majority 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. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. Illinois Department of Public Aid, Amanda Attridge Henson 15. Much of the required information can be located on the patient's face sheet. 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. This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. F.Discharged/transferred to home under care of organized home health service organization 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. 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. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. 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. 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). Catherine McCabe California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Some states and organizations are on the cutting edge of multiple use of standardized data. Illinois Department of Public Health, Frank C. Lemus Turrant County Mental Health Mental Retardation Services, Randy T. Kohl These elements are unique to the UACDS. 20. American Medical Association, Cary Sennett, MD, Ph.D. 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. Qualifier for Other Diagnoses (inpatient), 28. 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. The personal/unique identifier is the element that is the most critical element to be collected uniformly. University of Iowa. National Association Children's Hospitals, George Arges Attending Physician Identification (inpatient), 22. Gender As recommended by the UHDDS and the UACDS. State of Washington Department of Health, Debra C. Hopkinson, RN, MS These activities could take several forms. D'Angelo, B.S., M.S. 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 Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. In addition to documenting whether the patient was discharged alive or died during the hospitalization, the patient disposition is an indicator of the patient's health status at the time of discharge and need for additional services. Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers. 17-23. 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. Social Security Administration, Andrew A. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. Dataset Summary. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. St. Peter's Community Hospital, Ron Horner, Ph.D. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Hartford Health Department, Clem McDonald, M.D. 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. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. To transmit electronic data C. To create a process for transmitting data to external users D. offices, the location of the usual or principal place of practice should be given. 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. On that same day NCVHS submitted to the DHHS Data Council its recommendations for standardizing 42 core health data elements, including demographic, socioeconomic, and health status information about a person and data specific to a person's encounter with the healthcare system on either an inpatient or outpatient basis. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. Office of the Assistant Secretary for Planning and Evaluation. After review of the data elements collected, the subcommittees decided to study in-depth six data clusters: The preliminary results of this project have been prepared. 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. "Payers" are defined as public and private entities that have contract responsibility for health care payment. 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. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka 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. One problem that was encountered was that of requesting what the private organizations consider proprietary information. 11. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. Consensus building on data elements and definitions was, as always, a complex issue. 8. National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. Patient's Expected Sources of Payment, 12. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. National Center for Health Statistics, Walter P. Bailey It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 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). In the future, the system will integrate non-HCFA subscribers. Selma C. Kunitz, Ph.D. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. Don L. Zimmerman, Ph.D. I need the ICD-10-PCS codes 2. B.Discharged/transferred to another short term general hospital for inpatient care Dave Baldridge 14. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. 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. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. 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. 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. Definitions must be refined and made available in standardized formats to data collectors. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. American Medical Association, Herbert G. Traxler, Ph.D. Congress of the United States, Vicki Hohner Where can the Uhdds data elements be found? 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. Circulate the report within the Department for review and constructive criticism. At present, there is no widely recognized instrument for measuring the functional status of children. MPH The currently recommended coding instrument is the ICD-9-CM. The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. In addition, the usefulness of both current/most recent occupation and industry as well as the addition of usual or longest held occupation and industry must be evaluated. Purpose: to identify data elements for a uniform minimum data set on ambulatory care CMS1500 (Claim form for Medicare/Medicaid Outpatient claims) is main vehicle used to collect UACDS data elements . A data element is defined by size (in characters) and type (alphanumeric,. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. 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. Dept. Patient's Stated Reason for Visit or Chief Complaint (outpatient). Interregional Services, James P. Cooney, Jr., Ph.D. Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. Participation in the system will be voluntary for non-HCFA providers at first. They have influenced the claim forms on which Medicare and Medicaid data sets are based. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. 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. However, the activities envisioned by many participants go much farther than an advisory committee can handle. The set includes reasons for the encounter, living arrangements, and marital status. American Association of Retired Persons, Peg Douglas Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self The data sets promulgated by the NCVHS have become de facto standards in their areas for data collection by Federal and state agencies, as well as public and private data abstracting organizations. UNIFORM AMBULATORY CARE DATA SET. Current or Most Recent Occupation and Industry 2/, 16. ), particularly when used alone, and impediments (legal and otherwise) to its use. (9 days ago) What does uacds mean or stand for?UACDS means Uniform Ambulatory Care Data Set. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. 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 unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. 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. 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data elements is unique to uacds