National Center for Health Statistics, David P. Winchester, M.D. 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. HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. 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. 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 NCVHS notes that the Department of Veterans Affairs routinely collects this element, and thus approves the continued inclusion in this core list, pending a review of uses and users of this element. 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. U.S. Department of Health and Human Services 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. 28-31. 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. Seven confirmatory data items (including SSN) should also be collected when possible. "Payers" are defined as public and private entities that have contract responsibility for health care payment. Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. 24. 4. This identifier includes hospitals, ambulatory surgery centers, nursing homes, hospices, etc. The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution. 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. Colorado Hospital Association, Nancy Breen, Ph.D. 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. 01. Thomas P. Gross, M.D., MPH The set includes reasons for the encounter, living arrangements, and marital status. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman These elements are unique to the UACDS. Additional evaluation and testing are warranted for this important information. A total of 31 responses were received. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. Each item that is recommended must be considered carefully. Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? Department of Agriculture, Theresa Wulbrecht ANSI HISPP (Health Informatics Standards Planning Panel). Computer Network Architects, Inc. Barry Gordon HBO and Company. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. 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. Provider Location or Address of Encounter (outpatient), 22. 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. 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. Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. Marital Status - The following definitions, as recommended by the NCVHS, should be used. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. Kaiser Foundation Health Plan, Matthew McKearn The Committee's 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. Indian Health Service, Robert Davis The intent is not to specify a data set for mandated external reporting; the list of recommended data elements is by no means exhaustive, and, unlike earlier activities, is not a "data set" to be used in a specific setting. Patient's Expected Sources of Payment, 12. The Committee recognizes the need for uniform, comparable standards across geographic areas, populations, systems, institutions and sites of care to maximize the effectiveness of health promotion and care and minimize the burden on those responsible for generating the data. Center for Health Policy Studies, Carrie Dunkle, RN Classify common law marriage as married. Vermont Health Care Authority, Michael G. Kassis Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. UNIFORM AMBULATORY CARE DATA SET. The data sets that are currently standardized are prime examples of satisfying multiple purposes with a single data set. 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. Medicare decided a PAYERID was needed because of the difficulty its contractors were having in transferring claims to other insurance companies, due to incomplete information or multiple names for payers. 29. A. The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. 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. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. To transmit electronic data C. To create a process for transmitting data to external users D. Permanente Medical Group G.Discharged/transferred to home under care of a Home IV provider 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. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. 9. 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. The Committee acknowledges that there are differences in coding guidelines for reporting diagnosis in inpatient and outpatient settings, and this may result in a lack of comparability in data between the two settings. As recommended by the UACDS, address should be in sufficient detail (street name and number, city or town, county, State, and Zip Code) to allow for the computation of county and metropolitan statistical area. Most organizations were supportive in wanting to 'get on board' with 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. Footnotes: 1/ element for which substantial agreement has been reached but for which some amount of additional work is needed; 2/ element which has been recognized as significant but for which considerable work remains to be undertaken. They have influenced the claim forms on which Medicare and Medicaid data sets are based. Office of the Assistant Secretary for Planning and Evaluation. American Medical Association, Zili Sloboda, Sc.D. Molly A. Anthony, Ph.D. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. The National Committee on Vital and Health Statistics (NCVHS) has undertaken a first step in bringing together leaders in the field to seek consensus on a small set of data elements that are often considered the core of many data collection efforts. Department of Health and Human Services, Cheryl Beversdorf Center for Health Research and Communications, Inc. Craig Zwerling, M.D., Ph.D. Current or Most Recent Occupation and Industry 2/, 16. Kaiser Permanente, Medical Economics, Kathleen H. Fyffe 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. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. 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. 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. On that same day NCVHS submitted to the DHHS Data Council its recommendations for standardizing 42 core health data elements, including demographic, socioeconomic, and health status information about a person and data specific to a person's encounter with the healthcare system on either an inpatient or outpatient basis. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. With the exception of the personal/unique identifier, they do not need to be collected at each encounter. 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. It is recommended that convergence of these guidelines be investigated. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. The Committee could recommend such an activity, but it would require departmental staff to actually design, input data, and monitor and update the site. The personal/unique identifier is the element that is the most critical element to be collected uniformly. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN 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. 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Definitions must be refined and made available in standardized formats to data collectors. 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. It is possible that the description of functional status may entail more than a single measure, thus needing space for more than one measure and/or an additional element to document the scale used. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. No EP studies. New York State Office of Mental Health, James T. Howell, MD Dataset Summary. In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. 25. The American Occupational Therapy Association, Inc. Barbara Lowery B.Discharged/transferred to another short term general hospital for inpatient care University of Colorado Health Sciences Center, Inpatient Administration, Charles J. Rothwell College of American Pathologists, Division of Government and Prof. Affairs. 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. 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. Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Population Criteria Initial Population AND Age > 65 year(s) at "Measurement Period" AND Although there is agreement that "payments" or "costs" are needed, most participants agreed that it is virtually impossible to collect these items consistently across time and locations. To measure the current state of the use of various data sets, the Committee contracted with the Center for Health Policy Studies (CHPS) in Columbia, MD to begin identifying major data sets already in existence, especially in the private field. Patient's Stated Reason for Visit or Chief Complaint (outpatient) 2/, 29. This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. 42. 36. 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. 8. and provide a thorough description of what you have chosen. Georgia Center for Health Information, Patricia K. Miller It might not be feasible to expect the record to be updated to include payment data when it becomes available. 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. Alexis A. Wilson Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." American Nurses Association, Larry W. Miller Principal Procedure (inpatient)- As recommended by the UHDDS, the principal procedure is one that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. 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. Social Security Administration, Andrew A. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. Facility Identification - The unique HCFA identifier as described above. A. 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. To retrieve electronic data B. 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. What does ambulatory care include? American Society of Ophthaimic Registered Nurses. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. The currently recommended coding instrument is the ICD-9-CM. 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. 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. Health Care Financing Administration, Steven B. Cohen Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Office of Inspector General. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. However, there was no clear-cut listing of mutually exclusive encounter locations or definitions to draw upon. 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. 10. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. 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. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. Location or Address of Encounter (outpatient), 21. Interregional Services, James P. Cooney, Jr., Ph.D. Date of Birth Month, day, and year of birth. Self-report and clinician measurements are each valuable, and having both available is especially informative. Center for Mental Health Services, Corinne Kirchner, Ph.D. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. At the present time, standards- setting organizations should assign place holder(s) for this element. Include the full name of the provider as well as the National Provider. 16. IM System, David Newman, M.D. Principal Diagnosis (inpatient) - As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 6. NCQA - National Committee for Quality Assurance, Yvonne Senturia, M.D., M.Sc. Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. Larry Deutsch, M.D., M.P.H. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. Children's Memorial Hospital, Ernest J. Sessa National Institutes of Health, David . 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. 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.) Together with marital status, this element provides a picture of potential formal/informal resources available to the person. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. Centers for Disease Control and Prevention. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. Review state-of-the-art of widely-used core data sets in the United States and other countries (including coding and formatting features that allow for flexibility); Obtain input, through hearings and other means, from the diverse parties who will report and use standardized data sets; Interact closely with recognized standards-setting groups; and. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Their continuing study is involved with more detailed data elements that relate specifically to the areas of mental heath, substance abuse, and long term care. 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. offices, the location of the usual or principal place of practice should be given. 20. The .gov means its official. Virginia Health Information, Charles MacKay 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. 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. 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. It is hoped that the system will improve the coordination of benefits, as well as providing access to information about health insurance and making it easier to track third party liability situations. ICD-10-PCS code for: 1. Problems could arise from adding and modifying data items and definitions too frequently. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. 1. 34. 28. This item would be collected at first clinical visit and periodically updated, at least annually. This element refers to living arrangements only. 32. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. 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. Race and ethnicity B. Health Care Practitioner Identification (outpatient), 21. UACDS. 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. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan 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. 17-23. Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). Columbia/HCA HealthCare Corporation, John Quinn Minnesota Department of Health, Trish Riley Much of the required information can be located on the patients face sheet. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Massachusetts Department of Public Health, Richard H. Friedman Type of Facility/Place of Encounter 1/, 19. Years of schooling has been found to be highly predictive of health status and health care use. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl The Committee recommends that the HHS Data Council: 2. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Attending Physician Identification (inpatient) 1/, 22. Additionally, a consensus must be reached on the unique personal identifier. 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.). From the respondents, a total of 138 different data elements were obtained. 33-35. Oklahoma Department of MH and SA Services, Don Eugene Detmer, M.D. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. Outcome Concept Systems, Inc. Ronald W. Wilson, M.A. 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) 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. 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. A lack of footnote indicates that the element is ready for implementation. University of California, San Francisco, Jaclyn Packer [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. 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