States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. and is the best alternative to insure the availability of small area data. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. A large number were collected by only a few of the data sets. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. With the assistance of the Center for Mental Health Services, SAMHSA, and a contractor, Webman Associates, a study was undertaken to identify and survey a representative sample of mental health, managed care, substance abuse, disabilities and long term care experts who would be willing to offer recommendations about the content of an ideal minimal data set for a health care record that is inclusive of the relevant information. 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. 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. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. Association of Maternal and Child Health Programs, Karl S. Finison New York State Office of Mental Health, James T. Howell, MD Office of the Assistant Secretary for Planning and Evaluation. 12. Interregional Services, James P. Cooney, Jr., Ph.D. American Psychiatric Association, Thomas C. Sawyer NYLCare Health Plans, Inc. Andrew Webber 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. The Committee recognizes that all practitioners may not be included initially in this system, but ultimately all should be included. Kaiser Foundation Health Plan, Matthew McKearn Samuel W. Warburton, M.D. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. A person currently married. Other data items are related to a specific episode of care and will be provided at each encounter. Children's Memorial Hospital, Ernest J. Sessa Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. A. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. 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. 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. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. 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). For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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. This item would be collected at first clinical visit and periodically updated, at least annually. Place holders will be set, and, in some cases data items and definitions decided on, before national and local public health agencies and organizations will be able to act. Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. Currently there is little or no input from the public health field for several reasons. Catherine McCabe One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. Patient's Expected Sources of Payment, 12. 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. Indian Health Service, Robert Davis Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. State of Florida Agency for Health Care Administration, Kathryn Huntley 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.) 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 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. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. A. Colorado Hospital Association, Nancy Breen, Ph.D. 25. 3. These data items include birth name, date of birth, place of birth, gender, and mother's first name. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. Selma C. Kunitz, Ph.D. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . 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. D.Discharged/transferred to an intermediate care facility (ICF) American Association of Retired Persons, Peg Douglas Oak Orchard Community Health Center, Geraldine Nicholson HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. Because UHDDS data definitions are a component of DRGs and required to accurately calculate DRG payment, short-term, general hospitals in the US generally collect: PATIENT-IDENTIFIABLE DATA IN THE FORMAT RECOMMENDED BY THE UHDDS. Association of State and Territorial Health Officials, D. Walter Biggs, III State of Washington Department of Health, Debra C. Hopkinson, RN, MS 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. What clothing brands were popular in the 50s? The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. Several major issues were raised that were broader than the discussions of specific data elements. 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. offices, the location of the usual or principal place of practice should be given. Health Care Financing Administration, Steven M. Melov 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. Uniform hospital discharge data set (UHDDS). It also may be required to verify benefits. 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. What is the essential clinical dataset? American Public Health Association, Linda Vader, RN, CRNO The report provides important background information on coordinators and promoters of standards development; lead standards-development organizations; organizations developing performance measures indicators; departmental organizations; international organizations; and others. Sex, age, and race of the patient. However, the activities envisioned by many participants go much farther than an advisory committee can handle. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. Maine Health Information Center, Florence B. Fiori, Dr.P.H. 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. In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." 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. A listing of the Core Health Data Elements grouped by level of readiness for implementation is provided after the section with the definitions of each data element. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. 35. Respondents have indicated a mixed use of this item for inpatients. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. California Department of Health Services, J. Henry Montes However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. 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. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. 28-31. 3. Illinois Department of Public Health, Michael T. Lundberg, B.S. Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS Four digits are recommended for the discharge year. A range of organizations was contacted including health plans/insurers, trade or professional associations, employers, data standards organizations, and Government. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. What is a list of recommended data elements with uniform definitions that are relevant for a particular use? 20. To obtain the latest plans, at its October 1995 meeting, the NCVHS held a session focused on Standards Development Organizations and related organizations. 23. UACDS. The UHDDS guidelines state all significant procedures are to be reported and a significant procedure is defined as one that is: Surgical in nature, or. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. Recommendations and linkage with the current project will be discussed. What does Lo Debar represent in the Bible? Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. D.Other (specify). The Committee recommends that the HCFA identifier be adopted when completed. 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. Facility Identification - The unique HCFA identifier as described above. In some instances this may be a symptom or an abnormal finding. 22. 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