The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. A listing of all participants in the two meetings as well as those who provided written responses at any point in the process is found in appendix E. The Committee reviewed all of the input received from the hearings, meetings, letters and other communications. The focus of the NCVHS effort has been on the content of the data to be transmitted, rather than the method of transmission. Centers for Disease Control and Prevention, Lynn E. Jensen, Ph.D. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. 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. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. External Cause of Injury - This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. A number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). This item attempts to define what actually motivated the patient to seek care and has utility for analyzing the demand for health care services, evaluating quality of care and performing risk adjustment. At present, there is no widely recognized instrument for measuring the functional status of children. New York State Department of Health, Steven Davis 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. Birth weight of newborn is readily available in the medical record and has singular importance for risk-adjustment outcome studies and health policy development related to maternal and infant health. American Association of Retired Persons, Peg Douglas The American Academy of Family Physicians, Barbara Faigin 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. The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or Why such data sets are needed in the current and evolving health care arena; What multiple functions they might accomplish for a variety of different users; What data elements (including definitions, vocabularies and coding structures) they might contain; and. 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). Emily Friedman Health Policy Analysis, Del Fulgencio 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. 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. This element refers to living arrangements only. UNIFORM AMBULATORY CARE DATA SET. Data quality is a perennial issue. The continuing expansion of types of payments and the combination of payments within groups is ever changing. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Date of Encounter (outpatient and physician services), 18. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. The MEDSTAT Group, Joel Diringer, JD. Examples include information on health behaviors, such as smoking and alcohol consumption; information on preventive services; language ability; severity of illness indicators; provider certainty of diagnostic information; information to link a mother's and infant's charts; information on readmissions and complications. The Committee recommends that the HCFA identifier be adopted when completed. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. Response was significant and positive to the Committee's request to review a set of core data elements that were identified after a series of hearings and other information- gathering efforts were completed. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. The .gov means its official. It is anticipated that the introduction of ICD-10 will alleviate this problem. Health Resources and Services Administration, Tameron Mitchell, R.D., M.P.H. An example of this could be NAHDO which could undertake to work with its members. Which of the following data elements is unique to UACDS A. Operative Report PREOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor POSTOPERATIVE DIAGNOSIS: Recurrent sigmoid volvulus and tumor OPERATION: Directions: Discussion Overview: Choose a specific commonly collected data set (UHDDS, CDC, NCDB, UACDS, OASIS, HEDIS, etc.) The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. The goal has been to develop a set of data elements with agreed-upon standardized definitions that, when needed in a data collection effort, can be used to collect and produce standardized data. An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. They currently are not developing a system of categories to accompany the IDs. Periodicity of assessment also is an issue. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. The Committee recognizes that this is an iterative process and has included in these recommendations several elements that have been proposed for standardization, even though no consensus currently exists concerning appropriate or feasible definitions. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. Sex, age, and race of the patient. 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. Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. Additionally, includes optional data elements to describe the patients living arrangements and marital status. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. Any new data items, as well as the old, must be produced with clear instruction on data collection and coding. Center for Health Policy Studies, Rachael Block Also, although different data sets may include the same data element, in most cases it was not possible to verify that the data collection instructions and definitions were the same. 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. Additionally, a consensus must be reached on the unique personal identifier. National Academy for State Health Policy, Marie Roberto, Dr.P.H. Core Health Data Elements Project Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). American Nurses Association, Larry W. Miller Which of the following data elements is unique to UACDS? UACDS. 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. Condition(s) should be recorded to the highest documented level of specificity. Investigate the formation of leadership sites within the Department for each of the standards-setting organizations. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. 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 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. 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. 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. No follow-up planned (return if needed, PRN), Referred elsewhere (including to hospital), No charge (free, charity, special research, or teaching), Mental Health and Substance Use History of Consumer and of Consumer's Family Members, Categorization and Coding of Wrap Around Services (including community-based services, housing assistance, job training, etc.). National Center for Health Statistics, Walter P. Bailey Some recommendations in the area of mental health and substance abuse are included here. 22. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. Provider Location or Address of Encounter (outpatient), 22. ICD-9-CM Vol. 13. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. 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. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). National Institute of Dental Research, NIH, T. J. Mathews The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Molly A. Anthony, Ph.D. St. Peter's Community Hospital, Ron Horner, Ph.D. There is already consensus among data collectors and users for a significant number of data elements, especially elements related to person descriptors and to selected information on inpatient and ambulatory encounters. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. National Association Children's Hospitals, George Arges Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. UACDS differs from UHDDS with data elements specific to ambulatory . 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. Participating organizations included: Although Committee members were aware in a general way of ongoing standards developments activities, this session focused on the need for action being required now and in the near future if the health care community is to obtain and maintain a presence as data standards are developed and finalized. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. However, the activities envisioned by many participants go much farther than an advisory committee can handle. C.Discharged/transferred to skilled nursing facility (SNF) State of Washington Department of Health, Maria Rey Additionally the move in the health care payment system to managed care has increased the need to be able to link data sets and individual records across time, facility, and broader geographic locations. Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. American Public Health Association, Linda Vader, RN, CRNO In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. It is of vital importance to participate in and/or be members of the numerous data standards groups. Standardized coding schemes, such as the Census Bureau's Alphabetical Listing of Occupation and Industry and the Standardized Occupation and Industry Coding (SOIC) software developed by the National Institute for Occupational Safety and Health, should be reviewed. A lack of footnote indicates that the element is ready for implementation. Providers, Insurers, and universities represented about 7 percent each. Course Hero is not sponsored or endorsed by any college or university. 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. 23. More recently, the Department has been asked by the Vice President to play a leadership role, working with the Committee, in accelerating evolution of public and private health information systems toward more uniform, shared data standards. National Perinatal Information Center, Mark J. Segal, Ph.D. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. These activities could take several forms. The number of standards-setting organizations is growing; however, all who addressed the Committee are actively seeking participation by a 'recognized' leader/group who can forge consensus for the health care information field. Moreover, in the electronic format, in most instances, payments would not be available at the time that patient and medical data are entered. The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. 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. National Association of Health Data Organizations. Gender - Male, Female. The currently recommended coding instrument is the ICD-9-CM. Department of Veteran's Affairs (19), Lora Kraus Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. 02. Type of Facility/Place of Encounter 1/, 19. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. 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. Institute for Health Policy Studies, UCSP School of Medicine, Christopher G. Chute, M.D., Dr.P.H. Virginia Health Information, Charles MacKay 28. Department of Health and Human Services, Cheryl Beversdorf 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. Department of Veterans Affairs, Assistant Secretary for Policy and Planning, Mary Dufour ASTM Committee E-31, Clifford P. Binder University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell https://www.health-improve.org/what-is-uacds-in-healthcare/ 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. 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 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. 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. Significant medical procedures performed. The National Committee on Vital and Health Statistics (NCVHS) and the Department of Health and Human Services, which it advises, have initiated and completed the first iteration of a process to identify a set of core health data elements on persons and encounters or events that can serve multiple purposes and would benefit from standardization. If you continue to use this site we will assume that you are happy with it. This element is currently collected on the HCFA 1500 form. Digits to accommodate problems surrounding the turn of the patient describe the patients living arrangements and marital status accommodate surrounding... Course Hero is not sponsored or endorsed by any college or university of transmission documented level of.... 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