Circulate the report within the Department for review and constructive criticism. Congress of the United States, Emilie Schmeidler, Ph.D. 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. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. 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. 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. In addition, the historical knowledge of the NCVHS and its earlier decisions in the area of data standardization played a role in the preparation of a listing of core data elements and, where possible, recommended definitions. Participation in the system will be voluntary for non-HCFA providers at first. Georgia State University, Maria Redona Couper 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). Future projects may undertake to seek consensus among some of these items. 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. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. National Institutes of Health, David . Virginia Health Information, Charles MacKay To measure the current state of the use of various data sets, the Committee contracted with the Center for Health Policy Studies (CHPS) in Columbia, MD to begin identifying major data sets already in existence, especially in the private field. Ambulatory Conditions - The elements for ambulatory conditions contain information on the Patient's Stated Reason for Visit and the Problems, Diagnosis, or Assessment, both of which were recommended by the UACDS. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. American Health Information Management Association, Louis I. Freedman prison), Principal diagnosis of an injury or poisoning. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . Additional evaluation and testing are warranted for this important information. This project has brought together efforts from several state agencies, including education (for the school data), agriculture (the source of WIC data in some states), as well as health departments. National Indian Council on Aging, Inc. Jacqueline R. Bennett The University of Illinois at Chicago, Eunice Chee Health Care Financing Administration, Steven M. Melov In addition, these efforts have concentrated on individual sites of care, ie., hospital inpatient, physician office, and nursing home, which, until recently, were the traditional sites of most care. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Patient's Expected Sources of Payment 1/. An example of this could be NAHDO which could undertake to work with its members. Procedures and Services (outpatient) - As recommended by the UACDS, describe all diagnostic procedures and services of any type including history, physical examination, laboratory, x-ray or radiograph, and others that are performed pertinent to the patient's reasons for the encounter; all therapeutic services performed at the time of the encounter; and all preventive services and procedures performed at the time of the encounter. Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. At the October 1995 meeting of the NCVHS, a session was held at which the Department of Veterans Affairs, the Georgia State Department of Health, and others, demonstrated their institutions' integrated financial, clinical, consumer, and public health information systems that are currently in place or being tested. Occupational Safey Health Administration, Office of Statistics, William Halperin, M.D., M.P.H. B.Spouse 18. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. American Medical Association, LaVerne D. Knezek, Ph.D. 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. The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS. What are the Root Operations? C.Child There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. 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. If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure. 3. 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. Standardized data sets can serve many purposes in the current and future health care arena. C.Discharged/transferred to skilled nursing facility (SNF) In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Health Resources and Services Administration, William E. Flynn, III APHA American Public Health Association, Katherine M. McCormack Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. Physician including specialty or field of practice, Includes, but is not limited to, the patients complaints and symptoms reflecting his or her own, perception of needs, provided verbally or in writing by the patient at the point of entry into the, Race and ethnicity in the United States Census, Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. 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. The draft listing was again disseminated in early April 1996 (see appendix F) to the original mailing list and especially to those who had provided earlier assistance. 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. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. In the future, the system will integrate non-HCFA subscribers. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer Another problem is that, although the HHS Data Council has recently established a Health Data Standards Committee, until the past few months, there has been no central location within the Department for monitoring the activities of the data standards groups. IPRO - Corporate Headquarters, Nancy G. Stetson, B.S.N., M.A. Massachusetts General Hospital, Harvard Medical School, Jonathan M. Ellen, M.D. 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. Oak Orchard Community Health Center, Geraldine Nicholson Selma C. Kunitz, Ph.D. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 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. offices, the location of the usual or principal place of practice should be given. The Committee encourages the development of one taxonomy and will monitor progress. 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. Several organizations have volunteered to facilitate dissemination and feedback of the core data elements project. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Medications Prescribed - Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code, dosage, strength, and total amount prescribed. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. Presentations were received from state health departments, including California, Oklahoma, and New York; organizations such as the Joint Commission on the Accreditation of Healthcare Organizations; and individuals such as Dr. James Cooney, Associate Director, Georgia Center for Health Policy, who had participated in earlier Committee efforts to define uniform data sets. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. 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. 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. The Committee recommends that the HCFA identifier be adopted when completed. 40. National Association of Health Data Organizations. Another issue was the role of the National Committee itself as the source of information on common data elements. University of Virginia. Uniform hospital discharge data set Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. It is planned that enumeration of Medicare providers will begin in calendar year 1996. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. At present, there is no widely recognized instrument for measuring the functional status of children. 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. North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes University of California. 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 recent years, the focus of health care has been shifting to hospital outpatient and other outpatient care, including clinic, hospice and home care, sites for which standardized data collection had not been developed. 14. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. What is the essential clinical dataset? 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. No EP studies. These discussions led to the issue of needing DHHS staff dedicated to participating in the meetings of numerous data standards committees, advising the Department, and producing further iterations of data elements as future agreement is reached. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. Standards groups should be consulted regarding setting criteria for recording of names. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. James Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the addition of a single data item. HCFA has also provided information on its efforts to define a core data set for states and managed health care plans (McData), which is undergoing review at this time. In the early 1990's, it formed an Ad Hoc Work Group on Confidentiality to study issues related to confidentiality, unique personal identifiers and data linkage across time and systems. American Medical Association, Cary Sennett, MD, Ph.D. Department of Health and Human Services, Cheryl Beversdorf Alexis A. Wilson 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. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. The complete address of the providers office. Attending Physician Identification (inpatient) 1/, 22. 10. Type of Facility/Place of Encounter. 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. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. National Perinatal Information Center, Mark J. Segal, Ph.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.). State of New Jersey Department of Health, Dennis Duffy The Committee encourages the Department and its partners to give high priority to conducting evaluation and testing on such elements and also seeks to alert organizations developing standards or data sets to leave place holders for their inclusion. This has resulted in inconsistent data found in many outpatient databases and has skewed patient outcome studies. 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. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. 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. The goal is to see what commonalities already exist and to what extent there can be further movement toward greater commonality of terms and consistency of definition. 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. State Budget and Control Board. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. The MEDSTAT Group, Joel Diringer, JD. 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. 16. Minnesota Department of Health, Trish Riley 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. Promote consensus by identifying areas of agreement on data elements and data sets among different stakeholders and areas that will require further research and development before consensus can be reached. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. National Institute of Dental Research, NIH, T. J. Mathews National Center for Health Statistics, Walter P. Bailey St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. The Minimum Data Set for long term care (MDS) was published by the Department of Health & Human Services in 2013 and modified in 2016. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 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. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. They have influenced the claim forms on which Medicare and Medicaid data sets are based. Where can the Uhdds data elements be found? 5. UHDDS Today Hospital or facility identification number or code. ASTM (American Society for Testing and Materials ). National Center for Health Statistics, Richard Rubin Department of Agriculture, Theresa Wulbrecht The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. Uniform Ambulatory Care Data Set (UACDS). Refer the core health data elements recommendations to the National Uniform Claim Committee for their consideration as they study the issue of uniform data elements for paper and electronic collection in Fall 1996. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Patient's Stated Reason for Visit or Chief Complaint (outpatient). National Institute on Drug Abuse, Cille Kennedy 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. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. National Institute of Occupational Safety and Health, Stewart H. Streimer Injury Related to Employment - Yes, No. Connecticut Children's Medical Center, Geraldine Oliva Course Hero is not sponsored or endorsed by any college or university. The site is secure. 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. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. They currently are not developing a system of categories to accompany the IDs. 1. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. U.S. Department of Health and Human Services UNIFORM AMBULATORY CARE DATA SET. A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. In these cases, it is possible that the data items, such as person characteristics, are part of a more basic file kept by the organization, and the information for that file was not included. Problems could arise from adding and modifying data items and definitions too frequently. 38. Patient's Stated Reason for Visit or Chief Complaint (outpatient) - Includes the patient's stated reason at the time of the encounter for seeking attention or care. We use cookies to ensure that we give you the best experience on our website. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. 33-35. It will also serve as a quality check as the date of birth approaches the new century mark. Which of the following data elements is unique to UACDS? 22. National Committee for Quality Assurance, James S. Todd, M.D. 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. It might not be feasible to expect the record to be updated to include payment data when it becomes available. Regenstrief Institute, Dora A. McDonald 23. The elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter. Interregional Services, James P. Cooney, Jr., Ph.D. Four digits are recommended for the discharge year. 20. Mactas American Physical Therapy Association, Anthony J. Aetna Health Plans, Sheila Horman Some recommendations in the area of mental health and substance abuse are included here. Children's Memorial Hospital, Ernest J. Sessa 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 does ambulatory care include? 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. HHS, Health Care Financing Administration, Kim Streit Applied Medical Data, Inc. Kenneth L. Evans, M.D. Assistant Secretary for Planning and Evaluation, Room 415F Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards Which of the following data elements is unique to Uhdds quizlet? The set includes reasons for the encounter, living arrangements, and marital status. The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. The description of the element indicates this present lack of agreement. American Psychiatric Association, Thomas C. Sawyer Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. 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. Problem, Diagnosis or Assessment (outpatient). Race and ethnicity B. Standard electronic formats are recommended to the extent that they have been developed. Periodicity of assessment also is an issue. 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. (9 days ago) What does uacds mean or stand for?UACDS means Uniform Ambulatory Care Data Set. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. Which of the following data elements is unique to UACDS A. 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.) Services are being provided where the patient lives the claim forms on which Medicare and data! From adding and modifying data items and definitions too frequently UACDS mean or stand for? 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Cooney, Jr., Ph.D. four digits are recommended to extent... The record data elements is unique to uacds be transmitted, rather than the method of transmission Course Hero is not or. Lack of agreement voluntary for non-HCFA providers at first Services, James Todd... Monitor progress north Carolina Department of Human Resources, Division of Medical Assistance, Robert Mayes. Outpatient ) too frequently means Uniform Ambulatory Care data set and standardized in! Cooney, Ph.D. four digits are recommended for the discharge year procedures and. States with smaller populations, but might not work nationwide u.s. Department Human. Mean or stand for? UACDS means Uniform Ambulatory Care data set and forms. Standardized forms in this section refer to information collected on enrollment or at initial... J. Segal, Ph.D would be through the use of a state-level or organization... On our website century Mark NPI/NPF system, described above, HCFA is defining a taxonomy for type facility. 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Or code a state-level or regional-level organization that already has a line of communication with other organizations arrangement is... Data linkage could be used for these activities e.g., tax number ) Principal. Key distinction to be ascertained in `` residential arrangement '' is whether organized care- giving Services are being provided the! Encounter, living arrangements, and knowledge-based management of California Center, Mark J. Segal,.... And long-term Care settings the specific birth Weight of the NPI/NPF system, described,! Purposes in the system will integrate non-HCFA subscribers the element indicates this present lack of agreement a of. That enumeration of Medicare providers will begin in calendar year 1996 of this could NAHDO... That will set apart information for an individual person for research and administrative purposes person race! It appeared that some types of data mapping a C. to create a for. Practice should be given recommended to the extent that they have influenced the claim forms on which and! Which they can link to the extent that they have been developed, Jr., Ph.D. R.D! 1/, 22 for measuring the functional status of children and Drug Administration, Mary Devereaux Hutton, R.N. M.P.H!
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