Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. UHDDS Today Hospital or facility identification number or code. and provide a thorough description of what you have chosen. 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. 17. Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. 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. Updates of activities in each of the agencies are presented to the Committee on a regular basis. 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.). Non-excision all debridement of stage three pressure ulcer of subcutaneous tissue of buttock. It will also serve as a quality check as the date of birth approaches the new century mark. G.Discharged/transferred to home under care of a Home IV provider Because agreement on a unique personal identifier has been 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. This element refers to living arrangements only. 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. What does UACDS stand for? OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. Of 18 trade or professional associations contacted, only four submitted data sets. (9 days ago) What does uacds mean or stand for?UACDS means Uniform Ambulatory Care Data Set. HBO and Company. Department of Agriculture, Theresa Wulbrecht Another issue was the role of the National Committee itself as the source of information on common data elements. U.S. Department of Health and Human Services A. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. 13. 4. Get access to this page and additional benefits: Provies the ICD-10-PCS codes 4. The Committee recommends that the HCFA identifier be adopted when completed. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . 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. 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. 18. The ICD-9-CM is the recommended coding convention. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. Anonymous These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. National Institutes of Health, David . Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. It is planned that enumeration of Medicare providers will begin in calendar year 1996. The instruction clarifies that only what is known to the highest level of specificity should be reported. No decisions have been made by the Department on any of these recommended revisions of either the UHDDS or the UACDS. ), particularly when used alone, and impediments (legal and otherwise) to its use. 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. 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. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. American Nurses Association, Larry W. Miller 01. 42. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. Oak Orchard Community Health Center, Geraldine Nicholson To retrieve electronic data B. 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. Legal Services of Middle Tennessee, Leonard Bourget 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 . Managed Behavioral Health News, Melvin Sabshin, M.D. Dr. Detmer identified four overarching issues: privacy and confidentiality, computerized patient records, standards and classification, and knowledge-based management. NYLCare Health Plans, Inc. Andrew Webber 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. 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. American Association of Retired Persons, Peg Douglas In order to have as wide a participation at the meeting as possible, both East and West coast meetings were held in Oakland, CA, in early November, and in Washington, DC, in early December. 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. 33. American Foundation for the Blind, Karen Kmetik 24. This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. St. Peter's Community Hospital, Ron Horner, Ph.D. The American Occupational Therapy Association, Inc. Barbara Lowery Emily Friedman Health Policy Analysis, Del Fulgencio Vermont Health Care Authority, Michael G. Kassis Seven confirmatory data items (including SSN) should also be collected when possible. 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. California Health Information for Policy Project, Nancy J. Kennedy, Dr.P.H. 19. Catherine McCabe These include the review and implementation of core data elements and definitions within departmental data collection activities; formation of public-private work groups to assist in promulgating data elements for which consensus has been reached or for undertaking additional study on critical elements for which there are no standardized definitions. The MEDSTAT Group, Joel Diringer, JD. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Previous experience indicates that at least some, if not many, of these data items have differing definitions. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. D.Discharged/transferred to an intermediate care facility (ICF) 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: Hi there, would you like us to [] Selma C. Kunitz, Ph.D. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. 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). In 1989, NCVHS approved the UACDS, recommending its use in. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. 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 Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. White, M.P.H., Ph.D. National Center for Health Statistics, Walter P. Bailey This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. Health Care Financing Administration, Steven M. Melov Sex Male or female 04. 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. Illinois Department of Public Aid, Amanda Attridge Henson Self-report and clinician measurements are each valuable, and having both available is especially informative. Other data items are related to a specific episode of care and will be provided at each encounter. Living/Residential Arrangement - The following definitions are recommended by the NCVHS: Multiple responses to this item are possible. Together with marital status, this element provides a picture of potential formal/informal resources available to the person. 4. 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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. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. California Department of Health Services, J. Henry Montes Aetna Health Plans, Sheila Horman Department of Health and Human Services, Cheryl Beversdorf Date of Birth Month, day, and year of birth. and is the best alternative to insure the availability of small area data. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). 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). UNIFORM AMBULATORY CARE DATA SET. 26. Paul Y. Ertel, M.D. If a reporting entity is using a different element or definition, explain why their current usage is preferable. Operating Clinician Identification (inpatient), 40. Source of payment categories, as recommended in the past, are no longer sufficient. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. 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. Provider Location or Address of Encounter (outpatient), 22. Course Hero is not sponsored or endorsed by any college or university. 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. 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. 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. Michael L. Glickman In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. Center for Health Policy Studies, Rachael Block University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell National Institutes of Health, Stanley C. Garnett 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. Information on multiple diagnoses is important for developing severity indexes and assessing resource requirements and use. Office of the Assistant Secretary for Planning and Evaluation. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Information is collected by a wide range of users and in a myriad of different formats. To retrieve electronic data B. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. 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. Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS 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. Who will have access to the database for research purposes, and to what data, has yet to be determined. (Currently approximately 40 states collect health data on inpatient hospital stays.) Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. Currently, such a staff does not exist. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. The currently recommended coding instrument is the ICD-9-CM. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. At the present time, standards- setting organizations should assign place holder(s) for this element. Using items such as first name of mother; first digits of last name; date of birth; place of birth, etc., matches could be obtained without identifying the individual. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. 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. It will also serve as a quality check as the date of birth approaches the new century mark. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. 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. A chart showing the distribution of all respondents by type of organization is shown in appendix D. Approximately 30 percent of respondents were from state and local governments, followed by professional associations and the Federal Government with 18 Percent and 17 percent respectively. 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. 12. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. 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. These data assist in the examination of disparities in stage of illness, care, and outcome, some of which have been documented in the past among racial and ethnic groups. Marital status is discussed in element 6. National Perinatal Information Center, Mark J. Segal, Ph.D. Operating Clinician Identification (inpatient) 1/, 23. IM System, David Newman, M.D. The currently recommended coding instrument is the ICD-9-CM. 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. Lovassen chapter 24 Case Scenarios 5.The patient was assaulted by an unknown assailant and had stab wounds (lacerations) to the chest and neck. There may be more than one health care provider identified: A.The health care practitioner professionally responsible for the services, including ambulatory procedures, delivered to the patient (health care practitioner of record) Include the full name of the provider as well as the National Provider. To this end, the Committee recommends that the Data Council: 3. 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. The immediate goal of the NPI/NPF project is to support HCFA's Medicare Transaction System initiative by providing a single, universal method for enumerating the providers who serve Medicare beneficiaries. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich UACDS Data Elements Data Element Definition/Descriptor Provider identification, address, type of practice Place of encounter Reason for encounter Diagnostic services Problem, diagnosis, or assessment Therapeutic services Preventive services Disposition Provider identification: Include the full name of the provider as well as the National Provider Identifier (NPI). Institute for Health Policy Studies, UCSP School of Medicine, Christopher G. Chute, M.D., Dr.P.H. Permanente Medical Group Applied Medical Data, Inc. Kenneth L. Evans, M.D. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. The increasing use of electronic data, the evolving managed care field, and the growing requirement for performance monitoring and outcomes research have made it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. 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. National Center for Health Statistics, David P. Winchester, M.D. HHS, Health Care Financing Administration, Kim Streit Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program.
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