St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. They currently are not developing a system of categories to accompany the IDs. 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. 17. American Occupational Therapy Association, Kitty Werner Patient's Expected Sources of Payment, 12. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Patient's Expected Sources of Payment - The following categories are recommended for primary and secondary sources of payment: 40A. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. Alexis A. Wilson Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich NYLCare Health Plans, Inc. Eugene Stanton Health Care Financing Administration, Steven B. Cohen 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. 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. Selma C. Kunitz, Ph.D. The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Where can the Uhdds data elements be found? We use cookies to ensure that we give you the best experience on our website. Deborah Lieberman, MHSA, OTR/L, PAOTA 32. But time is short; decisions are being made by organizations now. G.Discharged/transferred to home under care of a Home IV provider Periodicity of assessment also is an issue. 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. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. In some situations, it is possible that a free-form narrative will be collected in place of the codes, to be coded at a later point. Several states, including California, Oklahoma, and New York presented findings on using a combination of key data items to perform probabilistic matches. Phillippine Nurses Association of America, Karen Grady Health Care Financing Administration, Steven M. Melov Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. 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. H.Left against medical advice or discontinued care. 9. The set includes reasons for the encounter, living arrangements, and marital status. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. American Public Health Association, Linda Vader, RN, CRNO It is planned that enumeration of Medicare providers will begin in calendar year 1996. Type of Encounter - This element is critical to the placement of an encounter of care within its correct location, i.e., hospital inpatient , outpatient, emergency department, observation, etc. The Committee supports the HHS Data Council in its formation of the Health Data Standards Committee to focus attention on the needs for standardized data both within the Department and in the health care community at large and to foster collaboration and consensus with the major standards-setting organizations. Emily Friedman Health Policy Analysis, Del Fulgencio 19. Multiple responses are possible. Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. It remains unclear whether the modest health gains seen in low-income and racial/ethnic minority populations in the last thirty years will continue, considering the changes in the U.S. health care system. B.Discharged/transferred to another short term general hospital for inpatient care Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). 1. 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. 42. Future projects may undertake to seek consensus among some of these items. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. 24. 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. 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. 28-31. HHS, Indian Health Service, Office of Planning, Evaluation, and Legislation, Terry Nowakowski, M.S.W. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. 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). However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. New York State Department of Health, Steven Davis 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. Problems could arise from adding and modifying data items and definitions too frequently. Association of State and Territorial Health Officials, D. Walter Biggs, III At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. However, the activities envisioned by many participants go much farther than an advisory committee can handle. National Association of Health Data Organizations. 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. A total of 31 responses were received. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. The Committee recommends that the HCFA identifier be adopted when completed. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. 17-23. HHS, Health Care Financing Administration, Kim Streit Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. National Institute of Occupational Safety and Health, Stewart H. Streimer A lack of footnote indicates that the element is ready for implementation. 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. Managed Behavioral Health News, Melvin Sabshin, M.D. 20. National Committee for Quality Assurance, James S. Todd, M.D. American Medical Association, Zili Sloboda, Sc.D. There is less agreement on data definitions, even for data items that have been in the field for years. 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. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. Which of the following data elements is unique to UACDS A. 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. 31. 3. National Institute of Dental Research, NIH, T. J. Mathews Patient's Stated Reason for Visit or Chief Complaint (outpatient). 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 the very minimum, there need to be "place holders" provided to standards organizations to inform them that certain data elements are critical elements, even when the specific format of the items is currently undecided. Health Care Financing Administration, Christine Rice Health Care Financing Administration, Emily Friedman Some recommendations in the area of mental health and substance abuse are included here. In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. 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. Administration for Children and Families, Susan N. Postal Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. Race and Ethnicity - The collection of race and ethnicity have been recommended by the UHDDS and the UACDS, and these elements have a required definition for Federal data collection in Office of Management and Budget (OMB) Directive 15. American Medical Association, LaVerne D. Knezek, Ph.D. 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. Department of Public Health, Dan Rode DCPC/NCCDPHP/CDC, Raymond C. Zastrow Shortly after arrival in the ER, the patient's. I need the ICD-10-PCS codes 2. The type of data collected in each different facility's patient health records is established by required standards or regulations. Legal Services of Middle Tennessee, Leonard Bourget The American Occupational Therapy Association, Inc. Barbara Lowery Disposition of Patient (inpatient) 1/, 40. 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