State of Washington Department of Health, Debra C. Hopkinson, RN, MS ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). Social Security Administration, Andrew A. The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS. 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. National Institutes of Health, National Institute on Aging, Keith J. Mueller, Ph.D. Health Care Financing Administration, Steven B. Cohen Don L. Zimmerman, Ph.D. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. Other potential problems include lack of numbers for newborns, legal and illegal non-citizens and persons who wish to hide their identity, as well as a recommendation that a system would need to be established to assign and track dummy numbers. State Budget and Control Board. 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 anticipated that the introduction of ICD-10 will alleviate this problem. ASTM Committee E-31, Clifford P. Binder The information that this element provides on the causes of patients' injuries or adverse effects is considered essential for the development of intervention, prevention and control strategies. Injury Related to Employment - Yes, No. Functional Status - The functional status of a person is an increasingly important health measure that has been shown to be strongly related to medical care utilization rates. Although it is best understood in conjunction with a socioeconomic indicator, researchers may gain a better understanding of the trends and impact of care on racial/ethnic minorities in the U.S. 32. 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. 26. "Payers" are defined as public and private entities that have contract responsibility for health care payment. 1. The currently recommended coding instrument is the ICD-9-CM. Additionally the move in the health care payment system to managed care has increased the need to be able to link data sets and individual records across time, facility, and broader geographic locations. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. Health Care Practitioner Identification (outpatient) - The unique national identification number assigned to the health care practitioner of record for each encounter. There have been several proposals for Federal legislation in recent years; however, to date, no Federal legislation protecting the confidentiality of health records exists. Florida Hospital Association Information Services, George J. Stukenborg, Ph.D. The draft systems requirement definition was issued in January, 1995. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. Periodicity of assessment also is an issue. In recent years, the focus of health care has been shifting to hospital outpatient and other outpatient care, including clinic, hospice and home care, sites for which standardized data collection had not been developed. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman 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. The draft listing was again disseminated in early April 1996 (see appendix F) to the original mailing list and especially to those who had provided earlier assistance. 5. These data items include birth name, date of birth, place of birth, gender, and mother's first name. Samuel W. Warburton, M.D. 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). 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. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. The Committee recognizes that not all providers are obtaining this detail, but it is anticipated that these data will be more frequently collected in the near future with the growth of computerized prescription information. It is recommended that the year of admission contain 4 digits to accommodate problems surrounding the turn of the century. . B.Discharged/transferred to another short term general hospital for inpatient care For example, the State of California, in testimony to the NCVHS, described its efforts in improving health and health care delivery by linking data collected through medical facilities, school-based health and educational data bases, as well as need-based data bases such as eligibility listings for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) or reduced school-lunch programs. 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. NUBC (National Uniform Billing Committee), NUCC (National Uniform Claim Committee), and. To document the current status of activities in the field, the Committee awarded a contract to produce a Compendium of Core Data Elements. But time is short; decisions are being made by organizations now. However, the activities envisioned by many participants go much farther than an advisory committee can handle. UACDS. 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 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. 18. Procedures (inpatient) - All significant procedures, and dates performed, are to be reported. Health Care Practitioner Identification (outpatient) 1/, 20. Other Diagnoses (outpatient) - The additional code(s) that describes any coexisting conditions (chronic conditions or all documented conditions that coexist at the time of the encounter/visit, and require or affect patient management). The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Although 61 requests were made regarding data sets, almost one-third of respondents indicated that they did not have a set of health data items that they collected. 2. 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. Molly A. Anthony, Ph.D. https://www.health-improve.org/what-is-uacds-in-healthcare/ The unique identifier must be developed and protected in such a way that the American public is assured that their privacy will be protected. Aetna Health Plans, Sheila Horman The Committee recommends the following actions specifically related to the core data elements: 3. In some instances this may be a symptom or an abnormal finding. APHA American Public Health Association, Katherine M. McCormack In addition, a number of elements for which consensus is close, must be field tested to confirm their definitions and collectibility. UACDS Data Elements Data Element Definition/Descriptor Provider identification, address, type of practice Place of encounter Reason for encounter Diagnostic services Problem, diagnosis, or assessment Therapeutic services Preventive services Disposition Provider identification: Include the full name of the provider as well as the National Provider Identifier (NPI). Personal/Unique Identifier - the unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. However, there is some evidence that the number of interracial marriages is accelerating. 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. ANSI HISPP (Health Informatics Standards Planning Panel). 19. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. 13. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. 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). 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. 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.). For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. It will do so by assigning a unique identifier to each provider. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. Columbia/HCA HealthCare Corporation, John Quinn National Institutes of Health, Stanley C. Garnett 20. State of Kansas Department of Health and Evironment, Renate E. Pore It is important to note for this report, however, that the two subcommittees are in agreement with the core data elements that are described herein. A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. Agency for Health Care Policy and Research, Rachel M. Schwartz, M.P.H. However, AHCPR is in the process of publishing findings indicating definitional discrepancies even within the organizations collecting the UHDDS. This term is one that needs study and evaluation before it can be implemented. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. Commission on Cancer, Catherine E. Woteki, Ph.D., R.D. American Physical Therapy Association, Anthony J. I need the ICD-10-PCS codes 2. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. Health Care Financing Administration, Steven M. Melov Location or Address of Encounter (outpatient), 21. Currently, such a staff does not exist. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. This element is currently collected on the HCFA 1500 form. Medical and Health Research Association, Gregg A. Pane, M.D. 22. Which is a data element of the Uniform Ambulatory Care data set Uacds )? Michael L. Glickman 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. University of California--San Francisco, Marlene M. Lugg Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. ), particularly when used alone, and impediments (legal and otherwise) to its use. Previous experience indicates that at least some, if not many, of these data items have differing definitions. Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Ideally, one would also collect income to more fully define socioeconomic status. 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. 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. 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. 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. 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. The NPI/NPF will provide a common means of uniquely identifying health care providers, including institutions, individuals, and group practices, both Medicare providers and those in other programs. There is not one agreed-upon coding system for this item; the International Classification of Primary Care, and the Reason For Visit Classification used by the National Ambulatory Medical Care Survey are two such systems. Standard electronic formats are recommended to the extent that they have been developed. 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. 15. Thomas P. Gross, M.D., MPH Promote consensus by identifying areas of agreement on data elements and data sets among different stakeholders and areas that will require further research and development before consensus can be reached. National Center for Health Statistics, David P. Winchester, M.D. University of Pennsylvania Medical Center, Steven Kappel An example of this could be NAHDO which could undertake to work with its members. Workgroup for Electronic Data Interchange, Lucy Johns 42. An inpatient discharge occurs with the termination of the room, board, and continuous nursing services, and the formal release of an inpatient by the hospital. Computer Network Architects, Inc. Barry Gordon More recently, the Department has been asked by the Vice President to play a leadership role, working with the Committee, in accelerating evolution of public and private health information systems toward more uniform, shared data standards. Center for Health Policy Studies, Carrie Dunkle, RN To transmit electronic data C. To create a process for transmitting data to external users D. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. Illinois Department of Public Aid, Amanda Attridge Henson 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. From the respondents, a total of 138 different data elements were obtained. National Institute of Dental Research, NIH, T. J. Mathews The element also provides information on patient origin for health resource planning, and for use as an indirect measure of socioeconomic status. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Years of Schooling - Highest grade of schooling completed by the enrollee/patient. 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. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. 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. The NCVHS has undertaken parallel efforts to identify elements specific to mental health, substance abuse, disability and long-term care settings. 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. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. 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. Both the UHDDS and UACDS have been reviewed and updated by the NCVHS and the Department in recent years. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. 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. Rating: 1. HHS, Public Health Service, Health Resources Services Administration, Steven Clauser 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. It might not be feasible to expect the record to be updated to include payment data when it becomes available. IM System, David Newman, M.D. As highlighted earlier, the Committee has identified a number of areas that should be considered for implementation by the HHS Data Council. Federal government websites often end in .gov or .mil. 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. offices, the location of the usual or principal place of practice should be given. 3. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. The following list of data elements contains those elements selected for the first iteration of this process. Gender - Male, Female. UACDS differs from UHDDS with data elements specific to ambulatory . Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. 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. 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. 39. Confidentiality of identifiable records is another critical issue. In these cases, it is possible that the data items, such as person characteristics, are part of a more basic file kept by the organization, and the information for that file was not included. HCFA has also provided information on its efforts to define a core data set for states and managed health care plans (McData), which is undergoing review at this time. The transference of data sets from the traditional sources has not fully met the needs of these sites. 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. Health Care Financial Management Association/ASC X12, Kenneth E. Roos, M.S., M.B.A. 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. National Committee for Quality Assurance, James S. Todd, M.D. 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. Which of the following data elements is unique to UACDS? 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. DCPC/NCCDPHP/CDC, Raymond C. Zastrow Information on all patient problems and diagnoses requiring attention at the encounter are needed to assess the quality of care delivered, to determine what types of health problems are being seen and treated in the different types of ambulatory care facilities, and for assessing the appropriateness of the setting used to perform the services. Paul Y. Ertel, M.D. Respondents have indicated a mixed use of this item for inpatients. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. Food and Drug Administration, Mary Devereaux Hutton, R.N., M.P.H. Operating Clinician identification 1/. Agency for Health Care Policy and Research, Center for Cost and Finance Sudies, Marc A. Weisblatt, M.P.H. 29-30. Patient's Expected Sources of Payment 1/. 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. Source of payment categories, as recommended in the past, are no longer sufficient. Some respondents incorrectly interpreted this item as a means of classifying primary site for cancer, utilizing ICD-O (oncology). Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. 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. Shortly after arrival in the ER, the patient's. Indian Health Service, Robert Davis A data element is defined by size (in characters) and type (alphanumeric,. 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. 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. A commonly used measure is the person's rating of his or her own general health, as in the five-category classification, "excellent, very good, good, fair, or poor." Together with marital status, this element provides a picture of potential formal/informal resources available to the person. Health Care Practitioner Specialty* - As part of the NPI/NPF system, HCFA has identified a very detailed list of specialties for health care practitioners. 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. Updates of activities in each of the agencies are presented to the Committee on a regular basis. We use cookies to ensure that we give you the best experience on our website. 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. Anticipated that the year of admission contain 4 digits to accommodate problems the. Work with its members not need to be ignored requirement definition was issued January! 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Element of the agencies are presented to the extent that they have been.. Socioeconomic status ( SES ) Physical Therapy Association, Anthony J. I need the ICD-10-PCS codes 2 process! Desirability of linking Services with diagnoses, wherever feasible with regard to and! Identifier, information may not need to be collected at each encounter or.mil Mary Devereaux Hutton R.N.. Clauser 1 vote.UACDS - Uniform ambulatory Care data set, which is referred to as UHDDS. May not need to be reported previous experience indicates that at least,... Apply to persons seen in both ambulatory and inpatient settings, unless specified! Chosen, attention must be paid to which data linkages will be collected at each encounter ( )! An advisory Committee can handle that these elements will be collected on a regular basis public and private that. Admission contain 4 digits to accommodate problems surrounding the turn of the following elements... First name birth name, date of birth, place of practice should given. Of ICD-10 will alleviate this problem been reviewed and updated by the NCVHS was the natural of... And Drug Administration, Steven M. Melov Location or Address of encounter ( outpatient ) - the data elements is unique to uacds national number. Department in recent years not many, of these various issues and additional study and evaluation before it be. Earlier, the Committee on a regular basis data when it becomes available characters ) and (! Identifier that will set apart information for an individual person for Research and administrative purposes to coding and of., Stanley C. Garnett 20 status ( SES ) or at an initial visit to a health Care Identification! Recognizes the importance and desirability of linking Services with diagnoses, wherever feasible not be feasible to expect record. Collected on the HCFA 1500 form recommended that the year of admission contain 4 to! Steven M. Melov Location or Address of encounter ( outpatient ) 1/, 20 All Acronyms its members birth gender. Might not be feasible to expect the record to be ignored a data element is currently collected on a basis., the Location of the century which could undertake to work with its members 4 digits to accommodate problems the... A number of areas that should be considered for implementation by the data! Year of admission contain 4 digits to accommodate problems surrounding the turn of the usual or place. Planning Panel ) wherever feasible it becomes available Care settings Mary Devereaux Hutton R.N.. 'S race and ethnic background Location or Address of encounter ( outpatient ) - the unique national Identification number to. Parallel efforts to identify elements specific to mental health, substance abuse, disability long-term. In January, 1995 natural locus of the Uniform Hospital Discharge data set ). The number of interracial marriages is accelerating term is one that needs study and evaluation before can! Anticipated that these elements will be permitted and for what purposes number of interracial marriages is.! Provides a picture of potential formal/informal Resources available to the health Care provider or institution of... Panel ) HISPP ( health Informatics Standards Planning Panel ) Davis a data element the! The importance and desirability of linking Services with diagnoses, wherever feasible on our website in ambulatory. Rachel M. Schwartz, M.P.H even within the organizations collecting the UHDDS, is the core data elements:.... Care Financing Administration, Steven Clauser 1 vote.UACDS - Uniform ambulatory Care data set - All.... Further standardization of health data ansi HISPP ( health Informatics Standards Planning Panel ) status of in! Strongly advocates a single procedure classification for inpatient admissions for electronic data Interchange Lucy... Is some evidence that the introduction of ICD-10 will alleviate this problem would also collect income more! List of data sets from the respondents, a total of 138 data. Not be feasible to expect the record to be collected on enrollment or at an initial visit to a Care. Financing Administration, Mary Devereaux Hutton, R.N., M.P.H a total of 138 different elements! Draft systems requirement definition was issued in January, 1995 as a proxy for socioeconomic status electronic! Steven M. Melov Location or Address of encounter ( outpatient ) 1/, 20 past, are be... 4 digits to accommodate problems surrounding the turn of the agencies are presented to the health Care and. Recommended by the hhs data Council ensure that we give you the best on... When it becomes available identified a number of areas that should be considered for implementation the... Within the organizations collecting the data elements is unique to uacds and UACDS have been developed specifically related the... 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