data elements is unique to uacds

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 [] Gender As recommended by the UHDDS and the UACDS. compare data for inpatients and ambulatory patients in the same or among other facilities. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 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. National Institutes of Health, David . 25. Provide stable resources to the project to establish an interagency work group, with DHSS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. Condition should be recorded to the highest documented level of specificity, such as symptoms, signs, abnormal test results, or other reason for visit, if a definitive diagnosis has not been established at the end of the visit/encounter. 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." Department of Health and Human Services, Cheryl Beversdorf A person who has never been married or whose only marriages have been annulled. Procedures and Services (outpatient) - As recommended by the UACDS, describe all diagnostic procedures and services of any type including history, physical examination, laboratory, x-ray or radiograph, and others that are performed pertinent to the patient's reasons for the encounter; all therapeutic services performed at the time of the encounter; and all preventive services and procedures performed at the time of the encounter. USDA, Food and Consumer Service, Regina McPhillips, Dr.P.H. Operating Clinician Identification (inpatient), 40. American Foundation for the Blind, Karen Kmetik U.S. Department of Health and Human Services Federal government websites often end in .gov or .mil. A total of 31 responses were received. The currently recommended coding instrument is the ICD-9-CM. The .gov means its official. Medications Prescribed - Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code, dosage, strength, and total amount prescribed. In addition, there are some disabilities, such as severe mental illness or blindness, where ADLs and IADLs are not sufficient measures. 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. Hartford Health Department, Clem McDonald, M.D. The primary diagnosis is not part of the UHDDS, and in most diagnostic situations, the principal and primary diagnoses will be identical. The draft systems requirement definition was issued in January, 1995. The ICD-9-CM is the recommended coding convention. The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. American Psychiatric Association, Thomas C. Sawyer Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. The University of Illinois at Chicago, Eunice Chee 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. It is the expectation of the Committee that the health care field will find these recommended data elements to be fundamentally important for any collection of person and health care encounter data and will consider these elements and standardized definitions for inclusion in their data collection efforts wherever possible. F.Discharged/transferred to home under care of organized home health service organization Carries a procedural risk, or. Previous experience indicates that at least some, if not many, of these data items have differing definitions. They have influenced the claim forms on which Medicare and Medicaid data sets are based. 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 American Academy of Family Physicians, Barbara Faigin If a reporting entity is using a different element or definition, explain why their current usage is preferable. Congress of the United States, Vicki Hohner In addition, these efforts have concentrated on individual sites of care, ie., hospital inpatient, physician office, and nursing home, which, until recently, were the traditional sites of most care. Legal Services of Middle Tennessee, Leonard Bourget CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. 13. Department of Agriculture, Theresa Wulbrecht The National Provider Identifier and National Provider File (NPI/NPF), currently under development by the Health Care Financing Administration (HCFA) and intended for implementation in 1997, could and should meet this need, if all providers are included. 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. More than 150 responses to this second request were received, including responses from the leaders in the health care and health care information fields. NYLCare Health Plans, Inc. Andrew Webber To assure the widest possible distribution, the document was also placed on the DHHS and NCHS Home Pages in an electronic format. Shortly after arrival in the ER, the patient's. 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.). 19. HHS, Agency for Health Care Policy Research, Ctr for Cost and Financing Studies. https://www.health-improve.org/what-is-uacds-in-healthcare/ 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. Connecticut Children's Medical Center, Geraldine Oliva Common data elements and areas for standardization will be considered as well as criteria for selection of data elements. 41. Sufficient penalties for breach of confidentiality either do not exist or are not enforced. (Currently approximately 40 states collect health data on inpatient hospital stays.) These activities could take several forms. This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. National Institute on Drug Abuse, Cille Kennedy HBO and Company. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. D'Angelo, B.S., M.S. American Occupational Therapy Association, Kitty Werner 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. ASTM Committee E-31, Clifford P. Binder 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. Race and ethnicity B. 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. Selma C. Kunitz, Ph.D. Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. 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. Location or Address of Encounter (outpatient) - The full address and Zip Code (nine digits preferred) for the location at which care was received from the health care practitioner of record (see 19A.). Conditions should be coded that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital or nursing home stay; or increased nursing care and/or monitoring. 22. American Physical Therapy Association, Anthony J. To identify the large number of organizations involved in various aspects of health data standards, staff at NCHS produced a report (see appendix H) describing the various groups by type of organization. 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Dave Baldridge The study also found that with the multiracial option there was a considerable decline in percentage terms (approximately 29 percent) of respondents choosing American Indian, Eskimo or Aleut. Principal diagnosis is required by most systems for inpatient reporting. National Institute of Occupational Safety and Health, Stewart H. Streimer The MEDSTAT Group, Joel Diringer, JD. Illinois Department of Public Health, Frank C. Lemus 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. Support the NCVHS in 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 health data element project recommendations. In 1989, NCVHS approved the UACDS, recommending its use in. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. American Medical Association, Mark Epstein, Sc.D. National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS Health Care Financing Administration, Steven M. Melov 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. 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. ), particularly when used alone, and impediments (legal and otherwise) to its use. 4. 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. It became obvious early in the meetings that the identification of core data elements, their definitions, and the consensus-building needed to encourage use of these items would be an ongoing and full-time activity for several years. Standards groups should be consulted regarding setting criteria for recording of names. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. HHS, HFCA, Bureau of Program Operations, Leo J. Nolan 5. To transmit electronic data C. To create a process for transmitting data to external users D. Qualifier for Other Diagnoses (inpatient), 28. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. 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. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. In some instances, lists of items were received with many basic data items not included. The Committee recommends that the HCFA identifier be adopted when completed. 17-23. 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. Because the PAYERID system is still being developed, and because HCFA currently has no plans to categorize payers, the Committee recommends the current UHDDS categories while encouraging continued study and evaluation of categories used by other data collectors. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Turrant County Mental Health Mental Retardation Services, Randy T. Kohl 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. 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. The Committee recommends the following actions specifically related to the core data elements: 3. University of California--San Francisco, Marlene M. Lugg 200 Independence Avenue, SW It will also serve as a quality check as the date of birth approaches the new century mark. Problem, Diagnosis or Assessment (outpatient). 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. Ronald Carlson These same data bases are being used to provide input to Federal surveys such as the National Hospital Discharge Survey (NCHS) and the Hospital Cost and Utilization Project (AHCPR). New York State Office of Mental Health, James T. Howell, MD The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. Health Care Practitioner Identification (outpatient), 21. 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. Alexis A. Wilson 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. Name - Last name, first name, middle initial, suffix (e.g., Jr., III, etc.). Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. 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. Whenever possible, the Committee and participants recommended collecting more detailed information on Asian and Pacific Islanders, as well as persons of Hispanic Origin. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional evaluation and testing must be undertaken to reach consensus on standardized content and definition. And now, with movement toward HMO's, PPO's, and other types of managed care, there may be a greater need to share identifiable data. 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. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Without a universal unique identifier or a set of data items that can form a unique identifier, it will be impossible to link data across the myriad of healthcare locations and arrangements. 20. Attending Physician Identification (inpatient), 22. University of Iowa. The Uniform Ambulatory Care Data Set (UACDS) regulates ambulatory care. Such a system would be helpful to the extent that it is feasible in the current highly dynamic market. 16. The database will contain payer names, billing addresses and business information. Data Elements UHDDS (Uniform Hospital Discharge Data Set) Personal Identifier A unique number identifying the patient, applicable to the individual regardless of health care source or third-party arrangement. End in.gov or.mil be helpful to the extent that it is feasible in the same or among facilities! Jr., III, etc. ) Darroch Forrest, Ph.D. D'Angelo, B.S.,.... 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