Most participants eagerly supported an independent committee, such as this, to gather input and advise the public health and health care communities. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. American Foundation for the Blind, Harvey A. Schwartz, Ph.D. 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. The currently recommended coding instrument is the ICD-9-CM. 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. 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). The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. 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. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. University of Virginia. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. Operating Clinician Identification (inpatient), 40. ICD-9-CM Vol. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Attending Physician Identification (inpatient) 1/, 22. DCPC/NCCDPHP/CDC, Raymond C. Zastrow 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. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich To retrieve electronic data B. The set includes reasons for the encounter, living arrangements, and marital status. 12. Which of the following data elements is unique to UACDS A. Virginia Health Information, Charles MacKay Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. Health Care Financing Administration, David L. Hobson 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. 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. Much of the required information can be located on the patients face sheet. National Indian Council on Aging, Inc. Jacqueline R. Bennett In the future, the system will integrate non-HCFA subscribers. 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. Operating Clinician Identification (inpatient) 1/, 23. Additionally, a consensus must be reached on the unique personal identifier. Hartford Primary Care Consortium, Inc. Thomas H. Dial, Ph.D. Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock B.Spouse FACEP Self-report and clinician measurements are each valuable, and having both available is especially informative. A data element is defined by size (in characters) and type (alphanumeric,. The ICD-9-CM is the recommended coding convention. 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. 11. 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. This group, or a separate group, could also be the focus for evaluating additions to the list of core data elements and for setting up methods for testing and promulgating the final products. 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. Federal government websites often end in .gov or .mil. It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. A lack of footnote indicates that these elements are ready for implementation. Currently, such a staff does not exist. 41. "Payers" are defined as public and private entities that have contract responsibility for health care payment. 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); ANSI (American National Standards Institute). Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. St Vincent Hospitals and Health Services, Michael L. Millman, Ph.D. A. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. NCQA (National Committee for Quality Assurance). In addition, the historical knowledge of the NCVHS and its earlier decisions in the area of data standardization played a role in the preparation of a listing of core data elements and, where possible, recommended definitions. 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. 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. Respondents & Meeting Participants, Roxanne M. Andrews, Ph.D. . What does UACDS stand for? UACDS. American Foundation for the Blind, Karen Kmetik G.Discharged/transferred to home under care of a Home IV provider The currently recommended coding instrument is the ICD- 9-CM. Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH The National Committee on Vital and Health Statistics has been a sentinel organization in the area of uniform data efforts. 23. Carries a procedural risk, or. Although the UHDDS has been in the field for two decades and its data items are widely used by government and private organizations, issues of quality and comparability remain. Department of Veterans Affairs, Veterans Health Administration, Deborah L. Parham, R.N., Ph.D. State of Texas Department of Health, Mike McGinty, Ph.D. 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. It is hoped that, as data collection evolves, certain data items, such as personal data, (i.e., date of birth, race, occupation) will only need to be collected at time of entry into a health care plan or to be updated on an annual basis, to reduce the burden of data collection. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. It will do so by assigning a unique identifier to each provider. Problems could arise from adding and modifying data items and definitions too frequently. C.Discharged/transferred to skilled nursing facility (SNF) 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. 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. Association of State and Territorial Health Officials, D. Walter Biggs, III In some instances this may be a symptom or an abnormal finding. Selma C. Kunitz, Ph.D. These discussions led to the issue of needing DHHS staff dedicated to participating in the meetings of numerous data standards committees, advising the Department, and producing further iterations of data elements as future agreement is reached. Secondary Source - The secondary source, if any, that will be responsible for the next largest percentage of the patient's current bill. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. This term is one that needs study and evaluation before it can be implemented. Southern California Public Health Association, John R. Lumpkin, M.D., M.P.H. Those present at the November and December 1995 NCVHS regional meetings agreed that the establishment of a unique identifier is the most important core data item. The Committee works closely with the National Center for Health Statistics, the Agency for Health Care Policy and Research, and the Health Care Financing Administration (HCFA). Information is collected by a wide range of users and in a myriad of different formats. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. A series of matrices were prepared that arrayed individual data elements in use or proposed for use by different organizations with the type of organization. Race and ethnicity B. The Committee recognizes the ongoing discussion of discrepancies between 'expected' and 'actual' sources of payment. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Currently there is little or no input from the public health field for several reasons. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. Years of schooling has been found to be highly predictive of health status and health care use. 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. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. Marital Status - The following definitions, as recommended by the NCVHS, should be used. A. 200 Independence Avenue, SW 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. 24. This issue represents more than just what item or set of items the identifier will include; it opens up the whole issue of data linkage, privacy, and data confidentiality with its relevant benefits and risks. Department of veteran's Affairs (191), W. Michael Boyson, M.H.A. Participation is voluntary, and HCFA, which is funding its development, has been working to get consensus about the kind of system that would be useful. 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. Social Security Administration, Andrew A. The type of data collected in each different facility's patient health records is established by required standards or regulations. 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. 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. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. In addition to requesting a written response from these experts, they were invited to participate in one of two special meetings organized by the Committee to discuss the project and to seek input. Department of Veterans Affairs, John A. Hornik, Ph.D. During the October 1995 and March 1996 NCVHS meetings, Dr. Don Detmer, University of Virginia, updated the Committee on international progress in data standardization and computerized patient records. In accepting these challenges, the Committee seeks to facilitate consensus development and incorporate the concepts of multiple use, continued change, and long-term evolution of core data elements into general thinking and practice. Ronald Carlson American Society of Ophthaimic Registered Nurses. To retrieve electronic data B. These elements are unique to the UACDS. 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.). However, the activities envisioned by many participants go much farther than an advisory committee can handle. 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. It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. 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. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. A total of 31 responses were received. UACDS differs from UHDDS with data elements specific to ambulatory . This taxonomy builds on previous NCVHS and departmental work and should be reviewed by the NCVHS and standards organizations. D.Discharged/transferred to an intermediate care facility (ICF) Each encounter generates a date of service that can be used to link encounters for the same patient over time. NUBC (National Uniform Billing Committee), NUCC (National Uniform Claim Committee), and. (Currently approximately 40 states collect health data on inpatient hospital stays.) Attending Physician Identification (inpatient) - The unique national identification number assigned to the clinician of record at discharge who is responsible for the discharge summary, as recommended by the 1992 UHDDS. Disposition (outpatient) - The health care practitioner's statement of the next step(s) in the care of the patient. Department of Health and Human Services, Cheryl Beversdorf Birth Weight of Newborn (inpatient) - The specific birth weight of the newborn, recorded in grams. Health Care Practitioner Identification (outpatient) 1/, 20. The description of the element indicates this present lack of agreement. Principal diagnosis is required by most systems for inpatient reporting. Department of Veteran's Affairs (19), Lora Kraus Health Resources and Services Administration, Lorne A. Phillips, Ph.D. 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. 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. 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) Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. The Committee recommends that the HCFA identifier be adopted when completed. Significant medical procedures performed. The American Academy of Family Physicians, Barbara Faigin Some states and organizations are on the cutting edge of multiple use of standardized data. and is the best alternative to insure the availability of small area data. Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. Any unit of data defined for processing is a data element; for example, ACCOUNT NUMBER, NAME, ADDRESS and CITY. At the present time, standards- setting organizations should assign place holder(s) for this element. The MEDSTAT Group, Joel Diringer, JD. 27. University of Pennsylvania Medical Center, Steven Kappel 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. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. The University of Illinois at Chicago, Eunice Chee 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. Shortly after arrival in the ER, the patient's. 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. Race and ethnicity B. UHDDS Today Hospital or facility identification number or code. HHS, HCFA, Office of Managed Care, Gordon Bonnyman every facility where ambulatory care is delivered. Maine Health Care Finance Commission, Harriet Starr National Institute on Drug Abuse, Cille Kennedy 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. 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. Uniform Ambulatory Care Data Set. Source of payment categories, as recommended in the past, are no longer sufficient. National Center for Health Statistics, Walter P. Bailey 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.). ), particularly when used alone, and impediments (legal and otherwise) to its use. Sex Male or female 04. If a reporting entity is using a different element or definition, explain why their current usage is preferable. 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. Current or Most Recent Occupation and Industry 2/, 16. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. Vermont Health Care Authority, Michael G. Kassis Columbia/HCA HealthCare Corporation, John Quinn Randall Spoeri, Ph.D. 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. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. 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. 3. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. 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. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. Health Level 7 Ernst & Young LLP, Jerri Regan Phillippine Nurses Association of America, Karen Grady 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. * As part of the NPI/NPF system, described above, HCFA is defining a taxonomy for type of facility. The currently recommended coding instrument is the ICD-9-CM. Computer Network Architects, Inc. Barry Gordon Connecticut Children's Medical Center, Geraldine Oliva The Committee has appointed a liaison to participate in selected meetings of the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X-12, a private sector coalition that is developing transmission standards for health data. Massachusetts Health Data Consortium, Inc. Nancy Stout, Ed.D. Before sharing sensitive information, make sure youre on a federal government site. 37. It might not be feasible to expect the record to be updated to include payment data when it becomes available. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 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. However, income questions are often considered intrusive, whereas years of schooling are more acceptable to respondents. 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. Uniform hospital discharge data set (UHDDS). 4. offices, the location of the usual or principal place of practice should be given. C.Child The instruction clarifies that only what is known to the highest level of specificity should be reported. 40. Health Resources and Services Administration, William E. Flynn, III HCFA, however, has estimated that there are approximately 30,000 individual payers in the U.S. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. 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. Center for Mental Health Services, Corinne Kirchner, Ph.D. Kunitz and Associates, Inc. Laura B. Landrum 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. Currently some states are using state facility identifiers, but the Committee recommends that these identifiers be superseded by the NPI/NPF. The Committee recognizes the importance of having both data items and identical definitions in order to compare and analyze data elements. Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. Date of Birth 4 digits for year of birth but 3 digits are adequate to capture the century Sex Male Race Ethnicity Another problem is that, although the HHS Data Council has recently established a Health Data Standards Committee, until the past few months, there has been no central location within the Department for monitoring the activities of the data standards groups. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. State of Florida Agency for Health Care Administration, Kathryn Huntley The response to the Committee's activities both through 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. Emily Friedman Health Policy Analysis, Del Fulgencio Armed with the extensive listing of potential data elements culled from the Compendium, in September 1995, the NCVHS contacted approximately 2,000 individuals and organizations in the health care utilization and data fields to seek their input in identifying those basic elements most in need of collection and/or in need of uniform definitions (appendix B). Process for these activities provider identifiers, for institutions and individuals input advise. 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