To retrieve electronic data B. Self-report and clinician measurements are each valuable, and having both available is especially informative. 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. 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. https://www.health-improve.org/what-is-uacds-in-healthcare/ 19. 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). National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS Connecticut Children's Medical Center, Geraldine Oliva 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. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. Deborah Lieberman, MHSA, OTR/L, PAOTA 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. Bureau of Vital Records and Health Statistics. The UACDS has never been officially promulgated by the Department, but a 1989 revision by the NCVHS and an Interagency Task Force has been widely circulated, as has a further refinement by the NCVHS in 1994. 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. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. The Committee recommends that the HCFA identifier be adopted when completed. Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. B.Discharged/transferred to another short term general hospital for inpatient care 40B. * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. National Academy for State Health Policy, Marie Roberto, Dr.P.H. Because agreement on a unique personal identifier is recognized as a key element to the successful establishment of core data elements, and their use, support the formation of a public-private working group to study and provide recommendations in this area. University of Pennsylvania Medical Center, Steven Kappel College of American Pathologists, Division of Government and Prof. Affairs. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. jr pk hg ws qk bc qp wi 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 Uniform Hospital Discharge Data Set (UHDDS) for inpatients Uniform Ambulatory Care Data Set (UACDS) for outpatient or ambulatory patients Minimum Data Set (MDS) for long-term care. MPH As recommended by the UHDDS and the UACDS. Association of State and Territorial Health Officials, D. Walter Biggs, III A. The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. 40. Several major issues were raised that were broader than the discussions of specific data elements. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. The priorities for recording an External Cause-of-Injury code (E-code) are: The collection of this element has been recommended by the UHDDS and the UACDS, and a separate element for its collection is included on the UB 92. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. National Perinatal Information Center, Mark J. Segal, Ph.D. It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. Capture of the full four-digit year of birth is recommended 03. Data quality is a perennial issue. They have influenced the claim forms on which Medicare and Medicaid data sets are based. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. Functional assessment scales must also be age-appropriate. A. Rating: 1. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. National Institute of Alcohol, Abuse, and Alcoholism, Benjamin C. Duggar, Sc.D. D'Angelo, B.S., M.S. 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. "Payers" are defined as public and private entities that have contract responsibility for health care payment. 37. Problem, Diagnosis or Assessment (outpatient). Who will have access to the database for research purposes, and to what data, has yet to be determined. Qualifier for Other Diagnoses (inpatient) - The following qualifier should be applied to each diagnosis coded under "other diagnoses," as was recommended in the 1992 revision of the UHDDS: This element is currently being collected by California and New York hospital discharge data systems; there is an indication that use of this qualifier can contribute significantly to quality assurance monitoring, risk-adjusted outcome studies, and reimbursement strategies. The complete address of the providers office. Recommendations and linkage with the current project will be discussed. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. Therefore, billed charges should be collected, at a minimum. Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. 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. To retrieve electronic data B. HRSA, Bureau of Primary Care, Mary Reister The Committee is concerned about the possible inclusion of a "multiracial" category, without an additional element requesting specific racial detail and/or primary racial identification, because of its anticipated impact on trend data and loss of specificity. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Workgroup for Electronic Data Interchange, Lucy Johns If the HCFA system does not have separate identification numbers for parts of a hospital (i.e., Emergency Department, Outpatient Department), an additional element (such as element 13) will need to be collected along with the facility ID to differentiate these settings. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. Favorable input has been received from a wide range of experts, and these elements should be compellingly useful both to states and to provider organizations. Uniform Ambulatory Care Data Set (UACDS). 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. The currently recommended coding instrument is the ICD-9-CM. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. 12. 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. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. However, the activities envisioned by many participants go much farther than an advisory committee can handle. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. 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. The Committee's efforts, first in the area of inpatient hospital data (the Uniform Hospital Discharge Data Set or UHDDS) and later in the area of ambulatory care (the Uniform Ambulatory Care Data Set or UACDS) have moved the country in the direction of achieving comparability in the health data collected by federal agencies, states, localities and the private sector, as well as in the international community. 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. Qualifier for Other Diagnoses (inpatient), 28. American Physical Therapy Association, Anthony J. 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. 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. 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. To transmit electronic data C. To create a process for transmitting data to external users D. The ICD-9-CM is the recommended coding convention. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. 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. Respondents have indicated a mixed use of this item for inpatients. For those elements that the Committee recommends as being ready to standardize, request each of the data collection entities within the Department to review the set of data elements and to match data contents and definitions with similar items that they are currently collecting or plan to collect. In some instances, lists of items were received with many basic data items not included. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. 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. UACDS differs from UHDDS with data elements specific to ambulatory . Injury Related to Employment - Yes, No. Of 18 trade or professional associations contacted, only four submitted data sets. 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. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. 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. American Hospital Association, Dawn Carlson, Ph.D. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. It became obvious that staff dedicated to participating in and monitoring the activities of these organizations is crucial if all relevant voices (including public health and epidemiology) are to be heard. 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. 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. National Center for Health Statistics, Walter P. Bailey Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. 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. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. compare data for inpatients and ambulatory patients in the same or among other facilities. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. 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. Include the full name of the provider as well as the National Provider. 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. Uniform hospital discharge data set NYLCare Health Plans, Inc. Eugene Stanton While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 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. Each encounter generates a date of service that can be used to link encounters for the same patient over time. One major reason is the staff and dollar resources required to travel to and participate in several meetings per group per year. Medical and Health Research Association, Gregg A. Pane, M.D. Aetna Health Plans, Sheila Horman With the use of UHDDS-defined data, for example, state and private abstracting systems have been providing comparable state and local data for health planners for many years. American Health Information Management Association, Louis I. Freedman The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. The currently recommended coding instrument is the ICD- 9-CM. 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. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Carries a procedural risk, or. Center for Mental Health Services, Corinne Kirchner, Ph.D. HHS, HCFA, Office of Managed Care, Gordon Bonnyman There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Gender As recommended by the UHDDS and the UACDS. National Indian Council on Aging, Inc. Jacqueline R. Bennett 11. The Committee works closely with the National Center for Health Statistics, the Agency for Health Care Policy and Research, and the Health Care Financing Administration (HCFA). Each item that is recommended must be considered carefully. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Emily Friedman Health Policy Analysis, Del Fulgencio Support implementation and testing activities for those data elements for which agreement on definitions has been reached and those for which minimal additional work is needed on definitional agreement. They do represent those items that are routinely collected in many efforts, such as basic person information, as well as items specific to inpatient or ambulatory care settings, such as provider information, diagnoses, and services. 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. 30. This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. Public and private participants have indicated a willingness to work together to disseminate information, test data elements, and utilize electronic means to ensure the widest dissemination of these activities. Office of the Assistant Secretary for Planning and Evaluation. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. 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. 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. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. 28. 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. 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. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. 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. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. 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. The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. National Institute on Drug Abuse, Cille Kennedy The categories in this element were recommended by the UHDDS for primary and secondary sources of payment. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich 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). Federal government websites often end in .gov or .mil. Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND There has been substantial agreement on data elements in these sets, but less agreement on data definitions. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. Operating Clinician Identification (inpatient) 1/, 23. Currently, data are often shared within a facility in an identifiable format. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. Managed Behavioral Health News, Melvin Sabshin, M.D. It is recommended that convergence of these guidelines be investigated. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. Providers, Insurers, and universities represented about 7 percent each. 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.). Other data items are related to a specific episode of care and will be provided at each encounter. (Currently approximately 40 states collect health data on inpatient hospital stays.) Georgia Center for Health Information, Patricia K. Miller University of California, San Francisco, Jaclyn Packer The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. 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. The Commonwealth of Massachusetts, Rate Setting Commision, Daniel J. Friedman, Ph.D. Date of Encounter (outpatient and physician services), 18. Such a system would be helpful to the extent that it is feasible in the current highly dynamic market. The currently recommended coding instrument is the ICD-9-CM. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. 33. American Medical Association, Zili Sloboda, Sc.D. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). Which of the following data elements is unique to Uhdds quizlet? DCPC/NCCDPHP/CDC, Raymond C. Zastrow The site is secure. Attending Physician Identification (inpatient), 22. Social Security Administration, Andrew A. Permanente Medical Group E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution Multiple responses are possible. UACDS. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. 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. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. Rural Health Advocacy Institute, Kevin Donnellan 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. Expected insurance payer number or code. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. 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. 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