The document outlines key healthcare data sets, including UHDDs, UACDs, MDS, OASIS, DEEDS, and EMDS, and explains their purposes in standardizing data collection for improved interoperability and performance assessment. It discusses the history and development of these standards, as well as the roles of various standard development organizations in shaping healthcare information standards. Finally, it highlights the importance of evolving standards and integration of data in electronic health environments to enhance patient safety and care quality.

1. STANDARDS
TMU – HCA Pharm. Dr. Alexander Bermudez
Rubashkyn

2. Outline
 Explain Health Care Data Sets and their purpose
UHDDS, UACDS, MDS, OASIS, DEEDS and
EMDS.
 Explain the standardization data collection efforts.
 Explain the five type of standards that need to be
in place to implement the Nationwide Health
Information Network (NHIN).
 Standard Development Organizations
 Evolving and Emerging Health Information
Standards
 Conclusions

3. Terminology
 Data (Data element): Representation of a
single fact of measurement.
 Information: Data that have been collected,
combined, analyzed, interpreted, and/or
converted into a form that can be used for a
specific purpose.
 Aggregate data: De-identified data extracted
from health records and combined eg. AMI
patient
 Data Set: A collection of recommended data
elements that have uniform definitions.

4. Standards
 Simplification, Unification, Uniform, Specification.
 Ensure that there is coupling and integration
between different elements.
 a. An acknowledged measure of comparison for
quantitative or qualitative value; criterion,
measure, guideline, example, model, guide,
pattern, sample, par, norm, gauge, benchmark.
 b. An object that under specified conditions
defines, represents, or records the magnitude of a
unit.
 c. Widely recognized or employed model or
pattern.

5. History Health Information
Standards
 XVII – London bills of mortality.
 1960 technology and computers
 Hospital Discharge Data Sets
 Nowadays, hospitals and Health Care
Organizations collect more data and develop
more information.
 The extensive use of information within and
across organizational boundaries demands
standards that promote interoperable
electronic interchange of data information.

6. Standardized Healthcare Data Sets
 Purposes of data sets
 Identify
the data elements that should be collected for
each patient.
 Uniformity in definitions.
 The Standardization makes possible
 Compare data from multiple facilities
 Comparison of data for:
 External accreditation
 Internal performance improvement
 Statistical studies
 Research activities

7. Standardized Data Sets in Health
Care
Uniforms Hospital Discharge Data Set (UHDDS)
Uniform Ambulatory Care Data Set (UACDS)
Minimum Data Set for Long-term Care and Resident
Assessment Protocols (MDS 2.0)
Outcomes Assessment Information Set (OASIS)
Data Elements for Emergency Department Systems
(DEEDS)
Essential medical Data Set (EMDS)

8. Uniform Hospital Discharge Data Set
(UHDDS)
 1969 Conference NCHS, National Center for
health services and research and Development
and John Hopkins University.
 All short-term general hospitals in US must collect
minimum set of patient data element UHDDS.
 1974 Federal government adopted the UHDDS for
Medicare and Medicaid programs.
 1983 The UHDDS definitions were incorporated to
the new prospective payment DRG.
 1986 All federal health programs adopted the
UHDDS

9. UHDDS
Back

10. Uniform Ambulatory Care Data Set
(UACDS)
 Set information about ambulatory care, or
outpatient.
 Approved by the National Committee on Vital
and Health Statistics.
 Some information is similar to UHDDS.
 Several information is specific, and focuses in
describe living conditions of patients.
 The goal of UACDS is to be incorporated in
federal regulations, UACDS has not been
incorporated, that is why is recommended its
used but not required.

11. UACDS
Back

12. Minimum Data Set for Long-term care (MDS
2,0)
 Uniform data important in the long-term care
setting
 Federally mandated.
 Standardized assessment form for nursing home
resident.
 MDS organizes data in 20 main categories, each
category includes list of choice and responses.
 MDS are used to develop a Resident Assessment
Protocol (RAP)
 Department of Health and Human Services (HHS)
implemented in 2009 the MDS 3,0.

13. Minimum Data Set for Long-term care (MDS
2,0)
Categories
1 .Demographic Information 11. Health conditions
2. Identification and background 12. Oral/nutritional status
information
3. Cognitive Patterns 13. Oral/dental status
4. Communication/hearing 14. Skin condition
patterns
5. Vision patterns 15. Activity pursuit patterns
6. Mood and behavior patterns 16. Medications
7. Psychosocial well-being 17. Special treatments and
procedures
8. Physical functioning and 18. Discharge potential and overall
structural problems status
9. Continence in past 14 days 19. Assessment information
10. Disease diagnoses 20. Therapy supplement for Back
Medicare PPS

14. Outcomes Assessment Information Set
(OASIS)
 Sponsored by the Health Care Financing
Administration (HCFA).
 Used for Medicare beneficiaries in home
health industry.
 This Data Set Include set of data items
collected on all adult home health patients.
 Data are used to assess the outcome and
measure the quality of the health care services
given to the patient.

15. OASIS
1. Demographics and Patient History
2. Living Arrangements
3. Supportive Assistance
4. Respiratory
5. Neurological
6. Psychological
7. Integument
8. Pain
9. Activities of Daily Living /
Instrumental Activities of Daily Living
10. Medications
11. Elimination Status
12. General Information
13. Emergent Care Back

16. Data Elements for Emergency
Department Systems (DEEDS)
 Developed by the Centers for Disease Control and
Prevention (CDC) and National Center for Injury
Prevention and Control (NCIPC).
 Uniform the collection of data in hospital based
emergency departments.
 DEEDS recommends the collection of 156 data
elements organized in 8 sections.
 DEEDS incorporates national standards for
electronic data interchange so its implementation
in an HER system facilitate communication with
other systems.

17. DEEDS
Patient identification data
Facility and practitioner identification
data
Emergency department payment data
Emergency department arrival and first-
assessment data
Emergency department history and
physical examination data
Emergency department procedure and
result data
Emergency department medication data
Emergency department disposition and
diagnosis data. Back

18. Essential Medical Data Set
(EMDS)
 Developed by the National Information
Infrastructure Health Information Network
Program NII-HIN
 Enhance effectiveness of emergency care
 Complement the DEEDS information, create a
health history for an individual patient.
 Emergency care has a critical impact on
patient survival, that is why is important collect
standardized and comparable data to assess
and improve the efficacy of emergency
treatment.

19. Standardized Data Collection
Efforts
Health Plan Employer Data and
Information Set (HEDIS)
Core Measures for (ORYX)
National Health Information Network
(NHIN)

20. Health Plan Employer Data and
Information Set (HEDIS)
 Sponsored by the National Committee for Quality
Assurance (NCQA).
 Standard performance measures designed to
provide purchasers and consumers of healthcare to
compare managed healthcare plans.
 The information collected about specific health –
related conditions is used to analyze and assess
outcomes of treatment.
 One of the goals of HEDIS is to encourage the
performance improvement for health plans and
practices, that is why HEDIS developed the
physician profile.
 Examples: Diabetes care, Adolescent Immunizations,
Smoking cessation programs, breast cancer screeningBack

21. Core Measures for ORYX
 Sponsored by Joint Commission.
 Integrate outcomes data and other performance
measurements data into accreditation process
about the core measures (Selected diagnoses
and conditions where the outcomes can be
improved by standardizing care.
 ORYX initiative uses nationally standardized
performance measures to improve the safety
and quality of healthcare.
Back

22. National health Information Network (NHIN)
 NCVHS explore the feasibility of a National health
Information Infrastructure NHII, that would allow
the electronic exchange of HI.
 This technology would increase patient safety,
reduce medical errors, increase efficiency and
effectiveness of healthcare, and contain costs.
 Under NHIN initiative efforts are focused on
creating standards and defining a universal
language of health information, accelerating
implementation of EHR.
 Besides technologies NHII includes values
practices, relationships, laws, standards, systems,
and applications that support all facets of
individual health, healthcare, and public health.

23. Core data elements and Data
content Standards
 Support the development of networked health
information systems.
 Interdependent dimensions
 NCVHS 2000 – Toward a National Health
Information Infrastructure.
 These three dimensions described, are a
useful division for considering health data
management requirement in HIM roles and the
future environment and practices for health
record management.

24. Personal Health Dimension
•Patient ID
Healthcare Provider Dimension •Patient industry •Personal health record
•Patient insurance •Non shared personal info
•Patient record elements outlook •Consent forms •Other elements as (Self-care track-
of provider. •Medication alert ers, instructions, communications)
•Clinical orders
•Audit-logs
•Practice guidelines
•Personal library
•Decision-support program
•Contextual information •De-identified information
•Mandatory reporting
•Community directories
•Public health services
•Vital statistics •Survey data •Inspection reports
•Population health •Public education
•risks materials
•Communicable diseases •Neighborhood
•Socioeconomic conditions environmental hazards
•Registries
Population Health Dimension
•Infrastructure data
•Planning and policy documents
•Surveillance systems
•Health disparities data
© NCVHS
2000b

25. Healthcare Information
Standards
 The previous standards were created for use in
paper-based health record, that is why can no be
longer accommodate for the current healthcare
delivery systems.
 FHA and HIE, have identified the need to develop
standards to support the CONECTIVITY and
INTEROPERABILITY.
 Data needs in an Electronic Environment.
 Health Organizations must integrate data.
 The goals only can be accomplished when every
system is using common data standards.

26. Healthcare Information Standards
(cont)
 Def: Describe accepted methods for collecting, maintaining and transferring
healthcare data elements between computer systems. These standards provide a
common language that facilitates and supports:
Exchanging
information.
Linking data in
a secure Sharing
environment. Information
Comparing
Communicating
information at a
within and across
regional, national,
disciplines and
and international
settings
level
Integrating
disparate data
systems.

27. Healthcare Information Standards
(cont)
“The long term vision for
Optimal Health Care
exchange is to enhance the
comparability, quality,
integrity and utility of health
information management
from a wide variety of
public sources through
uniform data policies and
standards”
NCVHS 2001
Imagine follow a recipe: no
standard measurements,
no instructions, nor specific
order etc….

28. Healthcare Information
Standards
Information Standards
Clinical Data Representation
Standards
Technical Standards
Medication Standards
Data Privacy and Security
Standards

29. Information Standards
 Content and Structure of HER.
 Structure and Content Standards establish and
provide, uniform definitions of data elements.
 Specify type of data to be collected in each data
field, width of each data field, content of each
data field.
I. HL7
II. ASTM E31 Committee
III. Identifier Standards

30. Health Leven Seven (HL7)
 HL7 is a non profit Organization. 1987
 Provides comprehensive framework and related
standards for the exchange, integration, sharing,
and retrieval of electronic, information.
 Consist of rules for transmitting demographic data,
orders, patient observations, laboratory results,
history and physical observations and findings, also
include message rules for appointment scheduling,
referrals, etc.
 CDA. Clinical Document Architecture (history,
physical reports, discharge summaries, progress
notes).
 SPL, HL7 v2 and v3, GELLO, Arden Sintax, CCOW

31. Health Leven Seven (HL7)

32. American Society for Testing
Material (ASTM) E31 Committee.
 Established in 1970
 ASTM develops standards related to EHR
 ASTM Standard E1384-02a
 The scope cover all types of health care services
 Purposes are outlined for ASTM practitioners for
content and structure of the EHR.
 Logical data consistently attached to patient record content
as (Physical test, Lab test, Diagnosis, Orders, Treatments,
Documentation, Patient info, orders, legal permissions)
 Explain relationship of the data coming from different
sources
 Provide a common vocabulary
 Create a unique setting view
 Map the content to select relevant biomedical and HIS

33. Identifier Standards
 Recommend methods for assigning “Unique
identification numbers” to individual, including
patients, healthcare providers, corporate
providers.
 Combination of numeric or alphanumeric
characters.
 Used within one facility or a single healthcare
system.
 There is not consensus on method.
 Identification number Social Security Number
(Identifier) instead DNI (not designed for being
universal identifier. Back
 Other sources for identify confirmation in health

34. Clinical Representation
Standards
 Includes clinical terminology / classification and
vocabulary system, lab and clinical data,
observation codes, drug codes, metadata.
 This tool encourage consistent descriptions of an
individual condition.
 Medical terminology extremely complex, Is not easy
standardize.
 Use of ICD and CPT uniform the terminology for data
capture.
 Code Sets are often featured as HL7
 There is not master set of data elements that
would facilitate HIE.
Back

35. Technical Standards
 Electronic Data Interchange/ e-commerce
• Structured transmission of data between
organizations by electronic means.
• Exchange medical, billing information
• Fast and cost effective transactions.
 ASCX12N or X12N
• Develop uniform standards for electronic
interchange of business transactions:
claims/encounters, attachments, enrollment,
disenrollment, eligibility.
• Payment/remittance advice, premium payments,
first report injury, claim status, referral,
authorization certification.

36. Technical Standards (cont)
 LOINC
 Used to provide standard set of universal names and
codes for identifying individual laboratory and clinical
results.
 Electronic exchange of laboratory results.
 IEEE 1073
• Provide for open systems communications in
healthcare applications.
• Interoperability standard for electronic health data
exchange from medical devices and patients,
optimized for the acute care setting.
 DICOM
• Standard which permits interchange of biomedical
images. Back

37. Medication Standards
 FDA National Drug Code (NDC) Drug codes and
(SPL) Labeling.
 FDA Center for Drug Evaluation and Research
Data Standards (CDER) manual.
• Several codes COMIS, DFS, CPRF, DRLS, DADS,
SPOTS.
• Strictly voluntary
 National Council for Prescription Drug Programs,
• NCPDP Transmitting prescription information between
prescribers, providers, and other organizations or
agents. Addresses electronic transmission of new
prescriptions, changes, refills, notifications,
cancellations.

38. Medication Standards (cont)
 Semantic Clinical Drug (SDC) of RxForm
• Provides standardized names for clinical drugs
(active ingredients) doses, forms, brand names,
RxForm is produced through HL7.
• Is a subset of RxForm, provide interoperability for
clinical drug nomenclature.
 LOINC Clinical Special Product Labeling (SPL)
• Structured product labeling, specification purpose
is to facilitate the submission, review, storage,
dissemination, and access to product labeling
information.

39. Medication Standards (cont)
Electronic Prescribing
Back

40. Privacy and Security Standards
 Mandated by HIPAA
 Ensure confidentiality and protection from
unauthorized disclosure alteration or destruction
effective security standards are especially
important in computer-based environments
because patient information is accessible to many
users in many locations
 ASTM and HL7 have developed security
standards.

41. Standards Development
 Standards development Organizations SDO.
(ISO, WHO, ASTM, ANSI, HL7)
 Process : Identifying, negotiating, drafting.
 Organizations that coordinate standards
development: ANSI
 ISO, International Standards
 Private and government organizations
influence development of standards.

42. Healthcare Standards
Landscape
© Hammond, William Edward; Jaffe, Charles; Kush
Rebecca Daniels. "Healthcare Standards
Development: The Value of Nurturing Collaboration
" Journal of AHIMA 80, no.7 (July 2009): 44-50.

43. Evolving and Emerging Health Information
Standards
• HIS are far from complete.
• Extensible Markup Language (XML): HTML
• XML allows data to be communicated from
one computerized system to another.
• No loss of integrity of data
• XML combined with existing classification
systems
• XML allows data in health record to be
organized.
• Can serve as a standard for exchange of HI
over the web.

44. Conclusions
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不懂。
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