Applied Medical Data, Inc. Kenneth L. Evans, M.D. To this end, the Committee has advised the Department on such matters as Federal-state relationships, nomenclatures and classification systems, core data sets, and access and confidentiality issues. Data sets received were assessed for their consistency with other data sets, particularly minimum data sets such as the UHDDS and the UACDS, the HCFA 1500 and the UB 92 data sets, and also with other current and future data sets under development by data standards organizations (ANSI). The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. 40. Health Care Practitioner Identification (outpatient) 1/, 20. Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. 34. ICD-10-PCS code for: 1. 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. Oak Orchard Community Health Center, Geraldine Nicholson Operating Clinician Identification (inpatient) 1/, 23. 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. 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. 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. Core Health Data Elements Project The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Much of the required information can be located on the patients face sheet. The continuing expansion of types of payments and the combination of payments within groups is ever changing. Principal diagnosis is required by most systems for inpatient reporting. This item would be collected at first clinical visit and periodically updated, at least annually. Thomas P. Gross, M.D., MPH National Perinatal Information Center, Mark J. Segal, Ph.D. 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. A second study is currently underway, one which will investigate core data elements in common use in data sets on persons with disability and/or persons receiving long term care. Patient's Relationship to Subscriber/person eligible for entitlement -, A.Self 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 element refers to living arrangements only. What potential problems, such as assuring data quality and preserving confidentiality of identifiable records, can be expected and what approaches might be used to address these problems. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution State of Washington Department of Health, Debra C. Hopkinson, RN, MS 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. Health Care Financing Administration. Recommendations and linkage with the current project will be discussed. Federal government websites often end in .gov or .mil. 17. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. BlueCross BlueShield of Minnesota. Health Care Practitioner Identification (outpatient), 21. HCFA is developing a new system, called the HCFA PAYERID project, which will assign a unique identifier to every payer of health care claims in the United States. In August 1994, the Department asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. It is of vital importance to participate in and/or be members of the numerous data standards groups. California Department of Health Services, J. Henry Montes Disposition of Patient (inpatient) - As recommended by the UB 92 and as an expansion of the 1992-93 UHDDS data element: A.Discharged to home or self care (routine discharge) The response to the Committee's activities through both 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. The National Association of Health Data Organizations has also opposed such an inclusion. Classify common law marriage as married. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. 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. In some instances, lists of items were received with many basic data items not included. Performance monitoring and outcomes research are two additional areas that are currently hampered by the inability to link data sets from various sources due to varying data elements and definitions. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? Health Care Planning and Policy, Edna Kamis-Gould, Ph.D. In August 1994, the Department recognized the National Committee's unique history in promoting standardization of health information when it asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. Vermont Health Care Authority, Michael G. Kassis What is Uacds? Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND 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. Another form would be through an organization that already has a WEB page; several organizations indicated that they would be willing to test the sharing of this information through their Internet sites. Common data elements and areas for standardization will be considered as well as criteria for selection of data elements. every facility where ambulatory care is delivered. Sex Male or female 04. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). At present, there is no widely recognized instrument for measuring the functional status of children. 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. 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. Illinois Department of Public Health, Frank C. Lemus During the discussion on including External Cause of Injury in the 1994 revision to the UACDS, CDC and labor and business groups urged collection of whether or not an injury occurred at work or was work-related. Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. Location or Address of Encounter (outpatient), 21. The UACDS is a recommended set, not a mandatory one. It will do so by assigning a unique identifier to each provider. 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. Carries a procedural risk, or. 38. National Association Children's Hospitals, George Arges It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. The currently recommended coding instrument is the ICD- 9-CM. 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. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. The currently recommended coding instrument is the ICD-9-CM. With relatives other than spouse, children, or parents, Residence where health, disability, or aging related services or supervision are available, Other residential setting where no services are provided, Other institutional setting (e.g. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. 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. Consensus has been reached on definitions for the majority 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. 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