data elements is unique to uacds

Date of Birth - Year, month and day - As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). 1) Identify the data elements should be collected for each patient 2) To provide uniform definitions for common terms UHDDS Uniform Hospital Discharge Data Sets Short Term general hospitals in the United states collect a minimum set of patient specific data/all the databases compiled from hospital discharge abstract system (inpatient stay) Of 18 trade or professional associations contacted, only four submitted data sets. NYLCare Health Plans, Inc. Andrew Webber Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. An official website of the United States government. Colorado Hospital Association, Nancy Breen, Ph.D. Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). Department of the Army, Headquarters, U.S. Army Medical Command, Michael D. Hennessey Health Care Financing Administration, David L. Hobson It also may be required to verify benefits. A total of 31 responses were received. The latter element, which describes all conditions requiring evaluation and/or treatment or management at the time of the encounter as designated by the health care practitioner, has been divided into two elements: 1) the diagnosis chiefly responsible for services provided, and 2) other diagnoses. ), particularly when used alone, and impediments (legal and otherwise) to its use. Additional evaluation and testing are needed on standardizing the health status element. 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. Respondents have indicated a mixed use of this item for inpatients. 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). 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). 40. Uniform Ambulatory Care Data Set (UACDS). In the 1992 revision of the Uniform Hospital Discharge Data Set (UHDDS), the NCVHS recommended "using the Social Security Number(SSN), with a modifier as necessary, as the best option currently available for this unique and universal patient identifier." New Hampshire Division of Public Health Service, Robert Roscoe Agency for Health Care Policy and Research, J. Lee Annest, Ph.D. 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. 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. 1. There is also concern that medical personnel may be confusing the definitions/uses of principal versus primary diagnosis. What clinical information is collected in the Uhdds? Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka Years of Schooling - Highest grade of schooling completed by the enrollee/patient. E.Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution It was felt that the Committee should consider designing a WEB page on the Internet that could be used for these activities. 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. 31. B.Spouse 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. NCQA (National Committee for Quality Assurance). The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Discharge Date (inpatient) - Year, month, and day of discharge as currently recommended in the UHDDS and by ANSI ASC X12. What is Uacds? Standards groups should be consulted regarding setting criteria for recording of names. Concurrent with these activities being undertaken by the full Committee, there are two related projects undertaken by the Subcommittee on Mental Health Statistics and the Subcommittee on Disability and Long Term Care Statistics. American Physical Therapy Association, Anthony J. 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. Operating Clinician Identification (inpatient), 40. 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 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. DCPC/NCCDPHP/CDC, Raymond C. Zastrow 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. Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades. The set includes reasons for the encounter, living arrangements, and marital status. Health Care Financing Administration, James Tierney What is the essential clinical dataset? 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. 29-30. 36. 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. ABLES Project Opfficer, NIOSH, Steven Rosenberg, Ph.D. In some instances this may be a symptom or an abnormal finding. As recommended by the UHDDS and the UACDS. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. A unique identifier such as the SSN in conjunction with at least one other data item or, alternatively, an identifier drawn from another distinct set of data items routinely collected presently would seem the most viable. Whichever method is used should be designated. 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. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. The complete address of the providers office. In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. 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. 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. UACDS differs from UHDDS with data elements specific to ambulatory . The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. State of Kansas Department of Health and Evironment, Renate E. Pore The Uniform Hospital Discharge Data Set, which is referred to as the 'UHDDS,' is the core data set for inpatient admissions. With the exception of the personal/unique identifier, they do not need to be collected at each encounter. There has been substantial agreement on data elements in these sets, but less agreement on data definitions. 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. 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. 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. Workgroup for Electronic Data Interchange, Lucy Johns At the present time, standards- setting organizations should assign place holder(s) for this element. It was thought that this was one of the reasons why some organizations, especially private employers, declined to participate. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. However, the information is still considered useful to collect for trend purposes and for some indication of patients' coverage by third-party payers. The Committee encourages the development of one taxonomy and will monitor progress. 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. 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. Respondents to this project welcomed the notion of a core data set and standardized forms in this area. 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. National Institute on Drug Abuse, Cille Kennedy 9. 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. 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. Participation in the system will be voluntary for non-HCFA providers at first. Functional assessment scales must also be age-appropriate. The draft systems requirement definition was issued in January, 1995. Race and ethnicity B. Kunitz and Associates, Inc. Laura B. Landrum There is less agreement on data definitions, even for data items that have been in the field for years. Illinois Department of Public Aid, Amanda Attridge Henson American Association of Health Plans, Louis H. Diamond, M.B.Ch.B. To transmit electronic data C. To create a process for transmitting data to external users D. 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