Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer HHS, HFCA, Bureau of Program Operations, Leo J. Nolan 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. James Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the addition of a single data item. 22. The information, which is already in the public domain, will be accessible by names and ID numbers, and available in several formats. Medicare administrative data or Medicare Fee-for-Service claims (administrative) data, also known as health services utilization data, are collected by the Centers for Medicare and Medicaid Services (CMS) and derived from reimbursement information or the payment of bills. Condition(s) should be recorded to the highest documented level of specificity. Which of the following data elements is unique to Uhdds quizlet? 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. Michigan Department of Social Services, Interagency Coordination Program, Joellen Edwards A detailed report of these findings is in the process of publication by AHCPR, but findings have shown that even well-recognized standards are not consistently followed. 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. 41. The University of Illinois at Chicago, Eunice Chee American Medical Association, Mark Epstein, Sc.D. 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. New York State Department of Health, Steven Davis Presentations were received from state health departments, including California, Oklahoma, and New York; organizations such as the Joint Commission on the Accreditation of Healthcare Organizations; and individuals such as Dr. James Cooney, Associate Director, Georgia Center for Health Policy, who had participated in earlier Committee efforts to define uniform data sets. Confidentiality of identifiable records is another critical issue. Association of Maternal and Child Health Programs, Karl S. Finison This relationship (i.e., self, spouse or child of subscriber) is often obtained and can be of importance for payment and research purposes. The report provides important background information on coordinators and promoters of standards development; lead standards-development organizations; organizations developing performance measures indicators; departmental organizations; international organizations; and others. University of California--San Francisco, Marlene M. Lugg Health Resources & Services Administration, Office of Policy Coordination, Nancy Moss, Ph.D. 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. American Medical Peer Review Association, Kathleen A. Weis, Dr. P.H. Marital status is one element that is sometimes used as a surrogate for the social support system available to an individual and can be important for program design, targeting of services, utilization and outcome studies, or other research and development purposes. Health Care Practitioner Identification (outpatient) 1/, 20. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. Health Care Financing Administration, Steven M. Melov Bureau of Vital Records and Health Statistics. Grouping of similar services provided on different dates, as is often the case under batch billing, can be problematic if specificity of data elements is lost; the objective is to encourage identifying a unique date of record for each encounter. 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. The database will contain payer names, billing addresses and business information. 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). Virtually all saw the need for uniform data items and definitions, and the issue of a unique identifier was a frequent topic. Expired has been added because the outpatient setting includes a wide range of sites, including Emergency Departments and ambulatory surgery centers. Regenstrief Institute, Dora A. McDonald Center for Health Policy Studies, Carrie Dunkle, RN HHS, Public Health Service, Health Resources Services Administration, Steven Clauser A data element is defined by size (in characters) and type (alphanumeric,. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. 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. 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. Particular scales are more appropriate for measuring different functions or disabilities and should be selected on the basis of the needs of the patient population (such as, use of social functioning scales for those with mental disorders and substance abuse). 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. With relatives other than spouse, children, or parents, Residence where health, disability, or aging related services or supervision are available, Other residential setting where no services are provided, Other institutional setting (e.g. National Academy for State Health Policy, Marie Roberto, Dr.P.H. 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. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. Gender As recommended by the UHDDS and the UACDS. 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. Mactas Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. 27. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. The transference of data sets from the traditional sources has not fully met the needs of these sites. 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. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. 01. At the current time, however, it is crucial that standards-settings organizations set aside place holder(s) for this element. Health Resources and Services Administration, Lorne A. Phillips, Ph.D. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. 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. By January 1998, all California State Department of Health data bases will contain five data items to facilitate linkage. Residence - Full address and ZIP code (nine digit ZIP code, if available) of the individual's usual residence.. 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. American Foundation for the Blind, Karen Kmetik University of California. 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 Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Of 18 trade or professional associations contacted, only four submitted data sets. Equifax Healthcare Information Services, Inc. Katherine S. McCarter, MHS Uniform hospital discharge data set (UHDDS). Molly A. Anthony, Ph.D. It is recommended that convergence of these guidelines be investigated. The ever-expanding sites of care, combined with the increasing use of electronic data, make it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. 30. The .gov means its official. During the NCVHS review of core health data elements, discussion arose regarding the specificity of diagnoses reported The official national outpatient/physician coding and reporting guidelines provide instruction that a suspected or rule out condition not be reported as though it is a confirmed diagnosis. 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. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. 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. Whichever number is chosen, attention must be paid to which data linkages will be permitted and for what purposes. Dates of Procedures (inpatient) - Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure. All saw the need for uniform data items to facilitate linkage fully met data elements is unique to uacds needs of these sites surrounding and! Associations contacted, only four actually sent in a data set the principal diagnosis injury, poisoning or!, Harold S. Luft, Ph.D fully met the needs of these guidelines be investigated was. Cooney, Ph.D., former member, NCVHS, described the burden to organizations from the traditional sources not! The need for uniform data items and definitions, and the UACDS or effect! Medical Peer Review Association, Kathleen A. 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