Bureau of Vital Records and Health Statistics. The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. 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. Location or Address of Encounter (outpatient), 21. This element is currently collected on the HCFA 1500 form. Sex, age, and race of the patient. 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. We use cookies to ensure that we give you the best experience on our website. Philippine Nurses Association of America, Lisa L. Culver, PT, MBA 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. New York State Department of Health, Steven Davis 19. Producing the compendium was a much more involved effort than was originally envisioned, and probably is representative of problems to be overcome in the future when standardization implementation is planned. Selma C. Kunitz, Ph.D. It is recommended that the year of birth be reported in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. Other data items are related to a specific episode of care and will be provided at each encounter. If a reporting entity is using a different element or definition, explain why their current usage is preferable. 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. This item already is collected by most state health data organizations collecting hospital discharge information and offers the only readily available information on the fiscal dimensions of care and the relative costs of different types of care. Consensus has been reached on definitions for some 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. The collection of this element allows for the investigation of issues surrounding health and health care by a person's race and ethnic background. Physician including specialty or field of practice, Includes, but is not limited to, the patients complaints and symptoms reflecting his or her own, perception of needs, provided verbally or in writing by the patient at the point of entry into the, Race and ethnicity in the United States Census, Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. National Institutes of Health, David . Georgia State University, Maria Redona Couper 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. Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. Additional evaluation and testing are needed on standardizing the health status element. 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. Primary Source - The primary source that is expected to be responsible for the largest percentage of the patient's current bill. Georgia Office for Health Care Data, Division of Public Health, Jayne Bertovich Illinois Hospital and Health Systems Association, Kathy Milholland, Ph.D., R.N. 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. It also includes other data elements such as Place of encounter to specify locations, reason for encounter that outlines the patient complaints and symptoms reflecting their own perceptions of needs, and diagnostic service that give a description of all types of service. Of these, approximately 70 percent provided information about their data elements. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Molly A. Anthony, Ph.D. 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. Department of Public Health, Dan Rode 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. 29. Oak Orchard Community Health Center, Geraldine Nicholson C.Discharged/transferred to skilled nursing facility (SNF) This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. Mayo Medical School, F. Lawrence Clare, M.D., M.P.H. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. 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. 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. 1 vote.UACDS - Uniform Ambulatory Care Data Set - All Acronyms. Administration for Children and Families, Susan N. Postal Collection of years of schooling has been recommended by the NCVHS and others as a proxy for socioeconomic status (SES). Self-report and clinician measurements are each valuable, and having both available is especially informative. 33-35. 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. 10. The transference of data sets from the traditional sources has not fully met the needs of these sites. 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. American Physical Therapy Association, Anthony J. Respondents have indicated a mixed use of this item for inpatients. 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. Federal government websites often end in .gov or .mil. The number of standards-setting organizations is growing; however, all who addressed the Committee are actively seeking participation by a 'recognized' leader/group who can forge consensus for the health care information field. Alexis A. Wilson 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). 26. A key distinction to be ascertained in "residential arrangement" is whether organized care- giving services are being provided where the patient lives. Personal Identification 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. Commonwealth of Virginia, Department of Medical Assistance Services, William R. Taylor, M.D., M.P.H. ANSI HISPP (Health Informatics Standards Planning Panel). ASTM (American Society for Testing and Materials ). This has resulted in inconsistent data found in many outpatient databases and has skewed patient outcome studies. The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. But time is short; decisions are being made by organizations now. The currently recommended coding instrument is the ICD-9-CM. UNIFORM AMBULATORY CARE DATA SET. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. University System of West Virginia, Curtis O. Porter 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). For those elements that the Committee recommends as being ready to standardize, request each of the data collection entities within the Department to review the set of data elements and to match data contents and definitions with similar items that they are currently collecting or plan to collect. 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? Circulate the report within the Department for review and constructive criticism. CORE HEALTH DATA ELEMENTS PROPOSED FOR STANDARDIZATION, 11. The Committee recommends that the HCFA identifier be adopted when completed. Patient's Relationship to Subscriber/Person Eligible for Entitlement, 12. Consideration of these various issues and additional study and evaluation are needed before recommendations can be made for standardizing functional status measurement. Race and ethnicity B. The Committee supports the HHS Data Council in its formation of the Health Data Standards Committee to focus attention on the needs for standardized data both within the Department and in the health care community at large and to foster collaboration and consensus with the major standards-setting organizations. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. Pennsylvania Health Care Cost Containment Council, P. John Seward, M.D. 39. However, the activities envisioned by many participants go much farther than an advisory committee can handle. 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. 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. Multiple responses are possible. 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.). Health Care Facility and Practitioner Identifiers - Each provider should have a universal unique number across data systems. 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. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. States have varying laws to protect the confidentiality of these data, and often the laws do not protect data that have crossed state lines. American Medical Association, Mark Epstein, Sc.D. 9. Some states and organizations are on the cutting edge of multiple use of standardized data. 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. Standards groups should be consulted regarding setting criteria for recording of names. Some thought needs to be given to completing this item for persons with no known residence or persons whose residence is outside of the United States. Mutual of Omaha Health Plans of Lincoln, Robert Koladner, M.D. 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. Include the full name of the provider as well as the National Provider. Date of Encounter (outpatient and physician services) - Year, month, and day of encounter, visit, or other health care encounter, as recommended by the UACDS and ANSI ASC X12. American Nurses Association, Larry W. Miller Assistant Secretary for Planning and Evaluation, Room 415F Office of Inspector General. 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. At present, there is no widely recognized instrument for measuring the functional status of children. If you continue to use this site we will assume that you are happy with it. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. 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. The Uniform Hospital Discharge Data Set, which is referred to as the UHDDS, is the core data set for inpatient admissions. At a minimum, the following classification is suggested: The critical distinction here is whether followup is planned or scheduled, as an indicator of continuing health problems and continuity of care. It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. 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 elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter. 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. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. Also, describe, to the extent possible, the provision of drugs and biologicals, supplies, appliances and equipment. Race and ethnicity 04a. A listing of all participants in the two meetings as well as those who provided written responses at any point in the process is found in appendix E. The Committee reviewed all of the input received from the hearings, meetings, letters and other communications. Standardized data elements will be vitally important in the evolving managed care field, where there is a need to follow individuals through a continuum of care and at multiple sites. NCQA (National Committee for Quality Assurance). Joint Commission on Accrediation of Healthcare Organizations, Susan B. Cahn, M.A., M.H.S. Gender As recommended by the UHDDS and the UACDS. Michael L. Glickman 31. Standardized data sets can serve many purposes in the current and future health care arena. The currently recommended coding instrument is the ICD-9-CM. In a number of instances, lists of data items were obtained, but without definitions. New York State Office of Mental Health, James T. Howell, MD Health Care Practitioner Specialty 1/, 27. 36. There are data items, such as health status and functional status, that are considered crucial elements, but for which substantial additional study and evaluation must be undertaken to reach consensus on standardized content and definition. 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. Uniform hospital discharge data set Years of Schooling - Highest grade of schooling completed by the enrollee/patient. Place the Committee's report, elements and definitions on an appropriate departmental Home Page as guidance to the field and as a means of encouraging use and soliciting further comments and suggestions while the report is under review within the Department. Whether an injury is work related or not can be of significant importance both in the area of injury prevention and in medical care payment. 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. Ronald Carlson Center for Health Policy Studies, Carrie Dunkle, RN Legal Services of Middle Tennessee, Leonard Bourget Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. University of Missouri, Kansas City, School of Dentistry, David K. Henderson, M.D. These elements are unique to the UACDS. 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. 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. 34. The UACDS is a recommended set, not a mandatory one. 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. Paul Y. Ertel, M.D. https://www.health-improve.org/what-is-uacds-in-healthcare/ 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. North Carolina Department of Human Resources, Division of Medical Assistance, Robert W. Mayes An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. Development of a unique identifier does not necessarily mean that the individual is identifiable to users. D.Discharged/transferred to an intermediate care facility (ICF) Which of the following data elements is unique to UACDS A. Data quality is a perennial issue. Percutaneous exchange of transvenous right atrial and ventricular leads of a pacemaker, which was initially placed three years ago; battery remains intact. New Hampshire Division of Public Health Service, Robert Roscoe Operating Clinician Identification (inpatient), 40. Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). New York State presented testimony that indicated that the last four digits of the SSN combined with the birth date were capable of linking data to a very high degree of probability. 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. No EP studies. 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." 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. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. 5. Date of Encounter (outpatient and physician services), 18. Bureau of Health Professions, HRSA, Fernando M. Trevino, Ph.D., M.P.H. 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. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. The Alan Guttmacher Institute, Kathleen A. Frawley It is a standardized, primary screening and assessment tool for health status that forms the foundation of the comprehensive assessment for all . With the exception of the personal/unique identifier, they do not need to be collected at each encounter. However, in the three remaining areas of health plans/insurers, government, and data standards organizations, the vast majority supplied data sets. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. The UACDS is a recommended set, not a mandatory one. University of Virginia. The collection of information on medications is crucial to understanding the health care encounter and the services provided to a patient. The major output of this project to date has been the recommendation of core data elements, definitions, vocabulary and classifications. Much of the required information can be located on the patients face sheet. 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. In the evolving managed care field, the need to follow individuals through a continuum of care and at multiple sites will become increasingly necessary. American Health Information Management Association, Louis I. Freedman 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. 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.) It is recommended that the NPF be the source of all unique provider identifiers, for institutions and individuals. From the respondents, a total of 138 different data elements were obtained. Office of Personnel Management, Jacqueline Darroch Forrest, Ph.D. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. Without definitions Years of Schooling completed by the enrollee/patient set, which is to! Consideration of these sites where the patient lives be through the use a! 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