DOCUMENTS AND COMMITTEE REPORTS

Series 4

Number 14

UniformHospitalAbstract:

MinimumBasicDataSet

A Report of the United States National

Committee on Vital and Health Statistics

DHEW Publication No. (HRA) 76-1451

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Health Resources Administration

National Center for Health Statistics

Rockville, Maryland
First issued in Vital and Health Statistics-Series 4-No. 14

December 1972

Reprinted as DHEWPublication No. (HRA) 76-1451
NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P.RICE, Director

ROBERT A. ISR4EL, Deputy Director

JACOB J, FELDMAN, Ph.D., Associate Director for Analysis

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System

ELIJAH L. WHITE, Associate Director for Data Systems

GEORGE P. FAILLA, Associate Director for Management

PETER L. HURLEY, Associate Director for operations

JAMES M. ROBEY, Ph.D., Assockte Director for Proflam Development

ALICE HAYWO OD, Information Officer
LtXterof acceptance

present Chairman of

Abraham M. Lilienfeld,

of the report on the Uniform Hospital Abstract: Minimum Basic Data Set to the

the U.S. National Committee on Vital and Health Statistics.

December 5, 1972

M.D.

Chairman, U.S. National Committee

on Vital and Health Statistics

Johns Hopkins University

615 North Wolfe Street

Baltimore, Maryland 21205

Dear Dr. Lilienfeld:

It is with pleasure that we accept the report, “Uniform Hospital Abstract: Minimum Basic Data Set,”

as prepared by the U. S. National Committee on Vital and Health Statistics. The Committee and the

subcommittee which it assigned to the project are to be congratulated for the completeness and high

caliber of this report, The included recommendations on concepts, definitions, and procedures for a

minimal uniform hospital discharge abstract data set represent a major achievement and should contribute substantially to better health care by providing the framework for improving hospital information systems and reducing hospital reporting burdens.

In implementing these re~ommendations, certain operational problems will undoubtedly arise. Many

of these can be anticipated by the field tests of the Committee’s recommendations which are currently

under way by the National Center for Health Services Research and Development in eight areas. These

efforts should provide important testing of the recommendations and perhaps suggest directions for

continuing improvements in a minimal uniform abstract data set.

Based on the deliberations of your subcommittee and the various correspondence on the subject, it

is clear that “total charges” as recommended by the 1969 Ah-lie House Conference are essential to

any sound hospital information system even though this item has been omitted from the Committee’s

basic data set. Total charges are given in all completed billing forms and the item is presumably not

needed as a separate entry on the medical abstract itself. Hopefully, experience gained in the combination of the basic data set and bill data will help resolve the issue of whether the charges item should

appear on both the uniform hospital discharge abstract and the standard hospital billing form (see

“Expansion of Data Set to Meet Special Needs, “ item 16, Charges, p. 16 of this Report).

We shall carefully study all of the Committee’s recommendations and the results of experience with

use of the recommended minimum items. Based on this study, we will then incorporate as many

recommendations as possible and appropriate in such ongoing Health Services and Mental Health

Administration programs as the National Center for Health Statistics’ Hospital Discharge Survey.

ZF%A....

Vernon E. Wilson, M.D.

Administrator, Health Services and

Mental Health Administration

.
FOREWORD

This report, prepared under the auspices of the U.S. National

Committee on Vital and Health Statistics, considers the purposes which

would be served by data on patients discharged from hospitals and the

minimum basic set of data items which it should be feasible to record

and which would serve most of these purposes. The importance of having data available on hospitalized patients is underscored by the large

volume of medical service rendered in hospitals-about 30 million

patients per year-and the high and increasing cost of hospital care.

In addition to specifying the minimum basic data set the report

provides deflni.tions of each item and classifications of the information

which would be recorded.

Forrest E. Linder, Ph. D.

Former Chairman

U.S. National Committee on

Vital and Health Statistics
U.S. NATIONAL COMMITTEE ON VITAL AND

HEALTH STATISTICS

Chairman Executive Secretary

LINDER, Forrest E, Ph.D. 1972 KRUEGER, Dean E.

Professor, Department of Acting Director, Office of Health

Biostatistics Statistics Analysis

School of Public Health National Center for Health Statistics

University of North Carolina Health Services and Mental Health

Chapel Hill, North Carolina 27514 Administration, PHS, DHEW

Rockville, Maryland 20852

Members

FIUZIER, Todd M. 1975

Assistant Director

Harvard Center for Community

Health and Medical Care

643 Huntington Avenue

Boston, Massachusetts 02115

GAFFEY, William R., Ph.D. 1973

California State Department of

Public Health

2151 Berkeley Way

Berkeley, California 94704

HUXTABLE, Deane L. 1974

State Registrar and Director

Bureau of Vital Records and Health

Statistics

Virginia State Department of Health

Richmond, Virginia 23208

LEWIS, Charles E., M.D. 1972

Professor and Head, Division of

Health Administration

School of Hygiene and Public Health

University of California at Los Angeles

Los Angeles, California 90024

LILIENFELD, Abraham M., Ph.D. 1973

Professor and Chairman

Department of Epidemiology

School of Hygiene and Public Health

The Johns Hopkins University

Baltimore, Maryland 21205

PARKE, Robert, Jr. 1972

Commission on Population Growth and

the American Future

726 Jackson Place, N.W.

Washington, D.C. 20506

PETERSON, Osler L., M.D. 1974

Professor and Acting Chairman

Department of Preventive Medicine

Harvard Medical School

Boston, Massachusetts 02115

RICE, Dorothy P., Mrs. 1975

Chief, Health Insurance Research

Office of Research and Statistics

Branch

Social Security Admnistration, DHEW

Washington, D.C. 20201

SHELDON, Eleanor Bernert, Ph.D. 1975

Sociologist and Executive Associate

Russell Sage Foundation

230 Park Avenue

New York, New York 10017

VENABLE, John Heinz, M.D. 1974

Dkector, Georgia Department of Public Health

47 Trinity Avenue, S.W.

Atlanti, Georgia 30334

WOOLSEY, Theodore D., ex officio

Director, National Center for Health Statistics

Health Services and Mental Health

Administration, PHS, DHEW

Rockville, Maryland 20852

vi
UNIFORM HOSPITAL ABSTRACT FORM SUBCOMMITTEE

Chairman

WEST, Howard

Director, Division of Health

Insurance Studies

Office of Research and Statistics

Social Security Administration, DHEW

Washington, D.C. 20201

CONNORS, Edward’ J.

Director, University Hospital

The University of Michigan Medical

Center

1405 East Ann Street

Ann Arbor, Michigan 48104

ENSIGN, James M.

Executive Director

Marshfield Clinic

Marshfield, Wisconsin 54449

HOERMANN, Siegfried A.

Director, Division of Health Resources

Statistics

National Center for Health Statistics

Health Services and Mental Health

Administration, PHS, DHEW

Rockville, Maryland 20852

ROBBINS, David

Director, Statistics and Control Division

Health Insurance Association of America

750 Third Avenue

New York, New York 10017

Secretary

MEADS, Sue

Medical Records Advisor

Division of Health Resources

Statistics, NCHS

Health Services and Mental Health

Administration, PHS, DHEW

Rockville, Maryland 20852

Members

SHINDELL, Sidney, M.D., LL.B.

professor and Chairman

Division of Preventive Medicine

Medical College of Wisconsin

1725 West Wisconsin Avenue

Milwaukee, Wisconsin 63233

WAI’ERSTRAAT, Mary- j

Executive Director

American Medical Record Association

Suite 1850

875 North Michigan Avenue

Chicago, Illinois 60611

JSRUEGER, Dean E., ex officio

Acting Director

Office of Health Statistics Analysis

National Center for Health Statistics

Health Services and Mental Health

Administration, PHS, DHEW

Rockville, Maryland 20852

vii
CONTENTS

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..--. ---- . . . . . . . . . .

Summ~yof Recommmdations. -.-. -... -.-- . . ..--. . . . . . . . . . . . . . . . . . . . . . .

Introduction .-.-. . . . . . . . . . . . . . . . . . . . . . . . ------------ . . . . . . . . ----------

Objectives and Approach--------------------- . . . . . . . . ------------- -----

GeneralConsiderations in aPatient DataSystem --------------------------

Source and Quali~ ofData . . . . . . . . . . . . . . . . . . . . . -.-. ..---- . . . . . . . . . . --

Maintaining Confidentiality of Information --------------------- . . . . . . . .

Authorizationsfor Release of Information and Assignment of Benefits -----

Content of Uniform Hospital Abstract Data Set----------------------- -----

Criteria for Inclusion of Items of Information ------ --------------------

The Items Constituting the Minimum Basic Data Set--------------------

Model Form --------- ---------------------------- -------------------

Recommended Procedures --------------------------- ------------------

Potential for Area, State, and National Hospital Patient Data Systems -------

Expansion of Data Set to Meet Special Needs. . . . . . . . ------------ . . . . . . . . . .

Future Revision of the Basic DataSet ------------------------------------

References ---------- --------*. --------- .--: --------- -------------------

v

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2

4

5

5

5

6

6

6

8

13

13

13

14

17

17

ix
UNIFORM HOSPITAL ABSTRACT:

MINIMUM BASIC DATA SET

SUMMARY OF

RECOMMENDATIONS

TheUniform Hospital Abstract Subcommittee

of the U.S. National Committee on Vital and

Health Statistics recommends that the following

items constitute the minimum basic data set for

hospital discharge abstracts:

1. Person Identification

Each patient is to be assigned a unique

number within a hospital that distin.

guishes him from all other patients in

that hospital.

2. Date of Birth

Month, day, and year of birth.

30 Sex

Male or female.

4. Race

White, Black, and other.

5. Residence

ZIP Code

6. Hospital Identification

A unique number within a data collecting system.

7.

8.

9.

10.

11.

Admission Date

Month, day, year, and hour (00-23) of

admission.

Dkcharge Date

Month, day, year of discharge.

Attending Physician

The physician who was primarily responsible for the care of the patient from

the beginning of this hospital episode.

(To be identified only by his unique number within the hospital.)

Operating Physician

This is the physician who performed the

principal procedure. (To be identified

only by his unique number within the

hospital.)

Diagnoses

AH diagnoses that affect the current

stay. Principal diagnosis is to be designated and is defined as : The condition

established after study to be chiefly

responsible for occasioning the admission of the patient to the hospital for

care. Other diagnoses to be listed are:

All conditions that exist at the time of

admission or develop subsequently which

affect the treatment received and/or
12.

13.

14.

the length of stay. Diagnoses that re.

late to an etirlier episode which have no

bearing on this hospital stay are to be

excluded.

Procedures and Dates

All procedures performed in operating

rooms are to be reported with the dates.

In addition to these procedures, all

other significant procedures are to be

recorded with the dates. A significant

procedure is one which carries an

operative or anesthetic risk or requires

highly trained personnel or special facilities or equipment. Some examples

of such procedures are: Cardiocatheterization, angiography, endoscopy, and

supervoltage radiation therapy.

When more than one procedure is recorded, the principal procedure is to be

designated. In determining which procedure is the principal, the following

criteria apply:

(a)

(b)

The principal procedure is one which

was performed for definitive treatment rather than one performed for

diagnostic or exploratory purposes,

or was necessary to take care of a

complication.

The principal procedure is that procedure most related to the principal

diagnosis.

Disposition of patient

(a)

(b)

(c)

(d)

(e)

Discharged to home (routine discharge)

Left against medical advice

Discharged or transferred

other organization

Discharged or referred to

ganized home care service

Died

to anan orExpected Principal Source of Payment

(select one)

(a) Self-pay

(b) Workmen’s compensation

(c)

(d)

(e)

(f)

(!3)

(h)

Medicare

Other government payments (including CHAMPUS, Medicaid)

Blue Cross

Insurance companies

No charge (fkee, charity, specialresearch, or teaching)

Other

The Subcommittee makes a number of other

recommendations, chief among them being:

1.

2.

Hospitals should develop procedures by

which a copy of the discharge abstract

that includep the items in the minimum

basic data set is forwarded to the business office for combination with the patient’s bill to support a claim for reimbursement by third-party payers.

Central abstract agencies should incorporate the minimum basic data set into

their systems. These agencies along with

with community health agencies-health

councils, comprehensive health planning

agencies, hospital councils-should promote the collection of abstracted data

from all hospitals in their areas and encourage maximum use of the assembled

data for the stated purposes.

INTRODUCTION

Thirty million patients enter the Nation’s

6,500 short-stay general hospitals each year.

These patients reflect a high concentration of

difficult diagnostic problems, intensive treat.

ment regimens including surgery, and lifethreatening illness. A substantial fraction of the

total burden of disease and illness, both acute

and chronic, is cared for in general hospitals.

About 45 percent of all expenditures for

personal health care are for care in hospitals

of all types and their outpatient services; as

compared with 22 percent for private physicians’

services.

Expenditures for hospital care (29.6 billion

in fiscal year 1971) and the proportion of the

total expenditures for health services are rising

faster than for any other component of health

services. Payment for hospital care is largely
through governmental programs (50percent) and

private insurance (36 percent) rather than through

direct payments by patients (13 percent).1

Thus, a large and costly segment of health

services is provided through one set of institutions and most of the payments for the cost of

these services are provided through another set

of institutions. This offers the possibility of introducing a substantial degree of standardization

and simplification of the mechanisms by which

claims for payment are prepared and in the demographic, diagnostic, and medical services data

which justify payment of claims. In this process

a valuable set of standard data on hospital patients would be recorded which is useful for

community planning, hospital administration,

patient management, and research purposes.

Data on health services can be collected

either from the providers or from the recipients

of services. The latter approach usually employs

household sample survey techniques and can

secure information on all types of services received by a defined population. It cannot supply

useful data on services received in a local area

or from an individual institution except at substantial cost. The information which can be obtained through interview surveys “ondiagnosis and

on specific services received is generally not of

good quality. Data collected from the providers

of service, on the ocher hand, are more specific,

of higher quality, and can be obtained from

records at much lower cost. If they are secured

from all providers of a particular type of service

in an area it is possible to relate the services to

the population of the area, as in the survey

approach.

Among the major providers of health services, hospitals are the group from which it is

most feasible to collect diagnostic and patient

services data on a continuing basis. Information

on patients discharged from hospitals is now being collected by the following organizations: (1)

for a national hospital sample by the Hospital

Discharge Survey, National Center for Health

Statistics, (2) for the majority of hospitals in

several local areas by central medical abstract

agencies, and (3) for a large number of hospitals

across the Nation by the Commission on Professional and Hospital Activities. Similar but

less detailed information is collected periodically

on a sample census of patients in long-term care

institutions. Data on patients living at home and on

the care they receive from private physicians

and outpatient services are generally not available.

Hospital discharge data, their uses, and

methods of collecting them were the subject of a

national conference in June 1969 which was

sponsored by The Johns Hopkins University, the

National Center for Health Statistics, and the

National Center for Health Services Research

and Development. The Conference considered the

requirements of public and private insurance

systems for diagnostic and patient services data

in support of individual claims for payment; the

needs for statistical data on groups of patients

for planning, administrative, patient management,

and research purposes; and the existing systems

for recording and assembling information on discharged hospital patients for both kinds of purposes. Twenty-five working papers presented to

the Conference and a review of the Conference

deliberations and recommendations have been

published.2

A major conclusion of the Conference was

that a wide variety of purposes could be served if

a limited number of standard items of information

were available on all patients discharged from

hospitals, and that it was feasible to propose that

“a minimum basic data set” on alI patients be

routinely recorded in a uniform manner. A list

of the items of information which should be considered for inclusion in the minimum basic data

set was suggested. It was recognized that for

certain purposes, mainly those related to studies

of patient management and to some kinds of research, the data set would be the starting point

for selection of cases for further study rather

than being all the information that would be required. In addition, the minimum basic data set

might have to be augmedt,ed to serve special needs

at particular times in local areas.

The U.S. National Committee on Vital and

Health Statistics was asked to establish a Subcommittee to study in detail the uses of hospital

discharge data and to recommend the items of

information which should be included in the minimum basic data set and the definitions and classifications to be applied in recording the information. It was further proposed by the Conference

3
that the National Center for Health Services Research and Development develop aplanfortesting

the feasibility of recording the data specified by

the Subcommittee in field tests, and the suitability and usefulness for the various purposes

of the items of information recorded.

This report reflects the Subcommittee’s deliberations and conclusions regarding the minimum basic data set for a uniform hospital discharge abstract. The preliminary experience of

the field tests has also been considered by the

Subcommittee and is reflected in this report.

OBJECTIVES AND APPROACH

The starting point for the Subcommittee’s

consideration of a minimum basic data set was a

review of the items of information now being

recorded on (1) the claims forms of the major

third-party payers for hospitalization and (2) the

abstract forms of the medical abstract agencies.

These were studied in relation to the essential.

functions of hospital discharge abstract systems

which had been summarized by the Conference

as follows: 3

1.

2.

3.

4.

5.

6.

To provide data for periodic review of

patient management patterns;

To provide data for efficient and economical hospital management;

To relate charges for hospitalization to

diagnostic and individual patient information;

To provide data for community and regional health planning bodies;

To provide data for health services and

epidemiological research; and

To provide a common insurance claims

form for use by private insurance carriers, Blue Cross, and the Social Security

Administration.

Some items of information about the discharged patient are essential to nearly every

anticipated use of the data, e.g., age and sex.

Other items would be essential for particular

uses of the data, e.g., specific surgical and other

procedures and the dates on which they were performed. The decision to include an item in the

minimum basic data set rests on the judgment as

to its essentiality for particular purposes and the

relative importance of those purposes.

The availability of particular items of information in the records of most hospitals was

taken as a constraint on the minimum basic data

set, that is, the Subcommittee did not include

items which would require most hospitals to set

up new procedures for securing information,

Problems which might be encountered in extracting information from the existing record

did not preclude the inclusion of a particular

item, because these problems could be evaluated in the field test.

Requirements of third-party payers for information about individual patients-personal

characteristics, diagnoses, and services received—were determined from the claims forms

currently in use, from model forms being considered for adoption, and from the personal

knowledge and experience of members of the Subcommittee. For items of information not required in the payment process the experience of

the medical abstract agencies was given great

weight. These agencies provide service to participating hospitals in the areas of hospital management, patient management, and medical record

indexing; to community planning agencies through

the preparation of hospital utilization statistics;

and less frequently to investigators carrying out

epidemiological and medical care research. Some

abstract agencies exercise these functions under

their own auspices.

Hospital utilization statistics are a valuable

product of an abstracting system, especially when

they relate to a defined population. Utilization

rates by age, sex, ethnic group, and residence,

for example, provide an information base for

planning future hospital care needs both for

the community and for individual hospitals.

When classified by diagnosis they also supply a

picture of a major segment of morbidity.

The major role of public and private insurance carriers in paying for hospital care offers the potential for widespread adoption among

the Nation’s hospitals of a uniform hospital discharge form coupled with a common billing form

to constitute a claims form with substantial savings in the cost of preparing and processing

4
claims. For this and other reasons the Subcommittee attached a great importance to the words

“minimum” and “basic” in selecting items of information for inclusion in the minimum basic

data set for the uniform hospital abstract form.

GENERAL CONSIDERATIONS IN A

PATlENT DATA SYSTEM

Source and Quality of Data

The organization and the quality of medical

records varies widely among hospitals. Their

orientation is primarily toward the establishment

of diagnosis and treatment of disease and secondarily toward the condition or functional status of

the patient, In most hospitals a summary is prepared at or after the discharge of the patient.

These differ among hospitals as to content and

within hospitals as to the care with which they

are prepared.

In many hospitals there is a Medical Record Committee whose responsibilities include

advising and supporting the medical record administrator in efforts to upgrade the completeness and accuracy of hospital records, These

activities should be continued and extended. It is

recommended that hospitals actively support

the recruitment and training of personnel for the

medical records department-administrators,

technicians, and clerical staff.

Present practice in preparation of insurance

claims in many hospitals is for staff of the business office to secure and record the diagnostic

and procedures data needed to support the claim.

The information so obtained is often inaccurate

and incomplete. Preparation of the hospital discharge abstract by staff of the medical records

department and its use as an integral part of the

insurance claim will provide better documentaS tion and facilitate the payment procedure.

The primary source of data for the hospital

discharge abstract will be the individual patient

medical record. Preparation of the abstract

should be fitted into the routine procedures and

normal flow of work of the medical records

department, It is likely that in many hospitals

the abstract form will be combined with, or take

the place of, discharge summary and/or record

face sheets now in use. It is recommended that

plans be worked out for the completion of dis.

charge abstracts promptly upon discharge of the

patient.

It is expected that the recording of the data

on the discharge abstract form, its use as part

of the claim, and for statistical purposes will

bring about improvement in the quality and reliability of information. Participation by a hospital in a central medical abstract system produces a strong incentive for improvement of data

because of the quality control efforts of the abstracting agency operating through day-to-day

contacts with the individual participating hospital.

Maintaining ConfidentialitY of Information

Patients generally authorize the release of

information by the hospital to the insurance carrier designated by the patient either on admission

to the hospital or when contracting for the insurance coverage. The Subcommittee’s concern with

invasion of privacy and confidentiality of information therefore relates only to use of the hospital discharge abstract by other agencies, such

as central abstract services.

The primary concern is with maintenance of

confidentiality of information about patients or

conversely the use of such information outside

the hospital in a way which reveals the identity

of the individual patient. Physicians, and to a

lesser extent hospitals, are sensitive about statistical data on groups of patients cared for by

thq physician or the hospital.

Two simple methods of maintaining the confidentiality of information about individual patients

which is in the hands of an abstracting agency are

(1) for the patient to be identified only by number

(to maintain control of records and enable backtracking to the hospital record to correct errors)

and (2) for the abstract agency to be made for this

purpose, an extension of the hospital’s medical

records department and subject to the hospital

policies on release of information about individual patients.

The Subcommittee recommends use of a

unique identifying number rather than the patient’s name in the minimum basic data set as

the method least likely to engender problems in

maintaining confidentiality of information. In

local areas where the functions of a central abstracting agency require the patient’s name, e.g.,

5
in preparing lists of patients admitted to hospitals

by particular physicians as part of the agency’s

service to hospitals, a suitable mechanism for

maintaining confidentiality should be worked out

between the abstracting agency and the hospitals

which it serves.

As hospitals assume more of the characteristics of community health agencies, statistical

data on the numbers and characteristics of the

patients they serve become of more interest and

concern to the community health planning bodies

and to the public. Major third-party payers,

welfare departments, and organized consumer

groups need and get access to this kind of information. The same trends apply, to a less degree and less universally, to data on the hospitalized patients of private physicians.

The experience of central abstracting agencies with respect to maintaining confidentiality

of statistical data on the patients of hospitals is

variable. Some report data on all hospitals while

others release data on a particular hospital only

to the hospital concerned. The Subcommittee

considers that most such data are matters of

community concern and recognizes that unnecessary restrictions on the use of data can be a

handicap to community planning agencies and in

fact to individual hospital administrations which

can benefit from knowing the experience of other

institutions

The Subcommittee has concluded that while

the desire to restrict use of data on individual

hospitals is generally decreasing, and rightly so,

the arrangements for use of data in a local area

must be mutually satisfactory y to the hospitals and

the central abstract agency. It therefore recommends that a hospital be identified on the uniform

hospital discharge abstract by a unique number

only and that decisions on dissemination of information about the patients of hospitals be left

to the option of the parties concerned. A similar

recommendation is made with respect to the

physician. The abstract agency would of course

have keys to the numbers for both hospitals and

physicians and so could produce data on patients

classified by the pertinent characteristics of

hospitals (e.g., type of control, bed size) and

physicians (e.g., type of practice).

Protection of confidentiality, of information

about patients is of course the major concern.

This issue had been expounded in the report of

the Conference on Hospital Discharge Data4 and

the report of the Twentieth Anniversary Conference of the U.S. National Committee on Vital

and Health Statistics.5

Authorizations for Release of Information and

Assignment of Benefits

It would not be. feasible to get patients’ signatures authorizing release of information to third

parties (insurance carriers and central abstract

agencies) after completion of uniform hospital

abstracts. This raises the question of whether

such third parties would accept an affidavit by

the hospital that authorizations are on file for

release of information and for assignment to

the hospital of benefits due from insurance carriers on behalf of the patient.

The Subcommittee’s opinion was that an affidavit by the hospital would be acceptable to

both central abstract agencies and insurance

carriers. This was supported by an informal

legal opinion with respect to private insurance

companies that an affidavit would be acceptable,

with the proviso that the hospital accept responsibility for the return of payments improperly

made by the carrier on the basis of the affidavit.

The Subcommittee therefore recommends that

hospitals secure an authorization by the patient

for release of information separate from the

uniform hospital abstract. This authorization

should be part of an integrated system of authorization secured by the hospital which includes

authorization for assignment of benefits to the

hospital.

CONTENT OF UNIFORM HOSPITAL

ABSTRACT DATA SET

Criteria for Inclusion of Items of Information

The Airlie House Conference had identified

the existence of “a basic core of information of

common interest to all users,” and had concluded

that “it would be desirable to collect this information in a uniform or compatible manner.” 6

Hence a number of criteria guided the selection and definition of the data set:

6
1.

2.

The item was one considered usejid to

most if not all the potential users. In

identifying the potential users, the Airlie

House Conference report listing was utilized t‘at least five important grouPs

could be identified who are dependent upon

adequate hospital statistics: hospital administrators seeking to run efficient and

economical services and to satisfy legal

and professional requirements; medical

staff responsible for patient management

and the quality of care rendered; a variety of State, regional, and national planning groups and legislative bodies; private and public third-party payers; and

researchers.” 7

In short, the first criterion was utility.

Unless substantially all the potential users required the data items on a routine

on-going basis, it was considered desirable to relegate an item to the optional

category, i.e., “data more efficiently collected by occasional studies or samples.” 8

Such data might be collected in a specific

local setting or for a limited period of

time to provide refinement of a basic data

item for a suecific purpose.

The item was one which could veadily be

collected with reasonable acczwacy. As

stated in the Airlie House Conference Repore “Feasibility was a major consideration in the choice of specific elements

for inclusion... These should be for the

most part data collected regularly as

part of the on-going operations of the

hospital, and relevant to the operational

needs of the hospital and its staff... Ease

of collection arid demonstrated usefu~ess

to the hospital greatly affect the care with

which the data are recorded.” 9

It was recognized that the medical records department of the hospital was to be

the site in which abstract data were to be

gathered. They would be gathered from the

source document with which this department normally deals, i.e., the patients’

medical record. Unless data for the basic

set were to be found in the medical rec3.

4.

ord or a feasible means identified for an

item to be routinely recorded in the medical record, an item could not be considered as a basic data item.

The item should not duplicate data aw%ilable from other sowrces. Since an objective in developing the data set was to

provide demographic, diagnostic, and

medical service data which, when coupled

with the financial information required

could serve the role of supporting a

claim for reimbursement, data items were

not considered which were normally collected as a business office function. Only

such identifying data as would be required

for linkage of the two data sets would be

common to both. Throughout the deliberations of the Subcommittee, relegation of

data items to the respective data sets was

made in order to arrive at the most efficient and most accurate data collection

system resulting from the eventual combination of items from the respective

sources.

Confidentiality of medical information

should be prese?wed. Both ethical and in

some areas legal requirements to maintain confidentiality of information concerning individuals guided the Subcommittee in the consideration of each data

item. The need to provide data on individual experiences can be compatible with

the need to protect the identity of the individual involved and the data items in the

basic data set were selected with this factor in mind. The basic data set standing

alone should not permit identification of

specific individuals. In those instances

where the data set would be utilized to

support claims data, the requisite authorizations to release medical information

would be required. Similarly, means are

provided for the identification of individual patients by those authorized to deal

with such information, while preserving

anonymity for those data users for whom

identification of specific individuals is

neither necessary nor authorized.

7
The Hems Constituting the

Minimum Basic Data Set

poses, record linkage to this extent would

satisfy current needs.

With the above criteria in mind, i.e., utility,

feasibility, nonduplication, afid confidentiality, the

specific data items and their definitions are presented along with comments concerning alternatives considered and the rationale for the choices

made.

1. Person identification. Each patient is to

be assigned a unique number within a hospital that distinguishes him and his hospitul vecovd from all others in that hospital.

Comment: As a basic need, each abstract

must identify a unique individual and his

record in the hospital so that the hospital

record may be retrieved for closer study

if required. If the abstract data are also

to be used to support claim data, a unique

number to identify both this and the companion record is required. Normally hospitals use the medical record number for

these purposes.

At this point in time all hospitals do not

yet possess a unit record system that

permits retrieval of all previous records

of the patients’ case within the specific

facility. In no community is there a means

for examining admissions to multiple

facilities through a unique numbering system yet developed. ‘l%ese are lmth desirable objectives.

The Subcommittee feels that in time the

individual’s Social Security Number

should replace individual hospital numbers, individual insurer’s numbers and

the like. At present, utilizing the Social

Security Number of the head of household

with a suffix for other household members

could provide an easily implementable

system for all type of patients’ identification and allow, for example, for the

assignment of numbers at birth which

would be retained until the individual

became a head of household or a member of another household, For most purThus, the Subcommittee chose to identify

the need for a unique number and couples

this with the suggestion that serious consideration be given to the adoption of the

head of household’s Social Security Number with a one digit letter suffix to identify all members of the family unit as the

number to be utilized.

2. Date of Birth. Month, day, and year of

birth.

Comment: The age of each individual receiving hospital care is an important piece

of data required for a variety of purposes.

Precision in obtaining this information is

increased if date of birth is recorded and

for such items as eligibility for age-related benefits the date on which eligibility

is established may be most important.

Also, if errors occur in recording of the

unique number (item 1 alwe) birth date

may be helpful in matching records.

Finally, birth date remains constant over

time, while age, obviously changes annually.

3. Sex. Male or female.

Comment: None should be required on

this item, except that there are some instances in which the sex of the patient

either has not or cannot be determined.

It is presumed that coding systems would

provide for an “undetermined” category,

but that is should be possible to collect

this data item accurately except in the

most unusual circumstances.

4. Race. White, Black, and other.

Comment: The accepted classifications

of the U.S. Bureau of the Census for race

are considered to be the ones to be utilized in a basic data set in order to provide uniformity and comparability of these

data with the demographic characteristics

of population data. There is a need for

such data to examine disease and utilization patterns.

8
5.

In specific localities where a significant

number of members of a particular racial

or ethnic group exist and it is desirable

to develop separate data for these groups,

supplementary categories may be utilized

so long as the data may be recombined

into the almve three categories for comparability with data obtained eLsewhere.

It would be expected that in the use of a

local option, the standard set of classifications developed by the U.S. Bureau of

the Census would need to be utilized in

order to assume c~mparability.

Residence. ZIP code.

Comment: The Subcommittee recognized

that ZIP code actually described the mailing address of the patient’s current residence. However, after much discussion,

the Subcommittee felt that ZIP code was

the only feasible means of categorizing

residence for a basic data set. As a

matter of utility, the current plans of

the U.S. Bureau of the Census to provide denominator data on a ZIP code basis

overcomes much of the former objection to the use of this geographic designation. As a matter of feasibility, the

ready availability of this designation as

opposed to census tract, etc., makes it

an easily recorded item with. a high degree of accuracy. As a matter of duplication, it is readily apparent that

claims forms would contain the specific

address and hence permit ad hoc studies

of residence if desired. And as a matter

of confidentiality, the possibility of ready

identification of individuals with their

specific address was considered undesirable.

As a matter of local option, the recording of ZIP code as a categorization of

location does not preclude a breakdown

into smaller areas for specific purposes

or on an ad hoc basis. The Subcommittee

felt that if at least ZIP code were collected on all hospitalized patients, a

wealth of data would be provided which is

currently not available.

6.

7.-8.

9.-1o.

Hospital Identification. A unique number

within a data collection system.

Comment: While much discussion was

held concerning the possibility of a single

numbering system for all hospitals in the

Nation, the Subcommittee felt that the

ability to identify a specific hospital and

segregate its data from those of the others

within a data system was all that could

reasonably be recommended. Some data

systems currently utilize the hospital

numbers assigned to indicate size and

ownership of the hospitals, geographic

location within a planning area, or the

like. Most needs to classify hospitals are

on a local or regional basis, hence the

options as to the type of number assigned

could most feasibly be left to the data

collection system.

Admission and Dischavge Dates.

a.

b.

Admission Date includes month, day,

year, and hour (00-23) of admission.

Discharge Date includes month, day,

and year of discharge.

Cornnzent: The desirability of collecting specific time of admission in

order to have data on the admission

patterns as they may affect utilization

of resources motivated the inclusion

of this information along with the admission date. Hour of admission utilizing 00-23 and disregarding minutes,

is recommended. This is considered

to result in greater accuracy in recording and provides easier manipulation of the data than the use of AM

and PM. It was considered preferable

to deal with the individual hours than

to attempt groupings which require

coding and may not be applicable universally.

Physician Identification. Each physician

must have a unique number within the

hospital. The attending physician and operating physician are to be identified.

a. Attending Physician. This is the physician who was primarily responsible

9
for the care of the patient from the

beginning of this hospital episode.

b. Operating Physician. This is the physician who performed the principal

procedure.

Comment:A number of comments

are in order. These relate primarily

to the limitation of the data set to the

two physicians identified, the definition of the physicians to be desi~ated,

and the nature of the unique number

to be assigned.

.

The Subcommittee, in dealing with

usual practice among hospitals and existing abstracting systems, elected to

restrict the basic data set to the identification of the two physicians of

greatest importance in the care of the

patient during the hospital episode.

It was the feeling of the Subcommittee

that the attending physician should be

identified with the expectation that the

physician so designated would havea

continuing key role throughout the total

hospital stay. Even when physicians

are practicing in groups, the Subcommittee strongly recommends that separate numbprs be assigned and utilized

for each individual physician.

The Subcommittee was also concerned

about the islentif ication of the physician

performing the procedure(s) if different from the attending physician, and

much discussion was held concerning

the limitation of the basic data set to

this one additional physician. Sentiment in favor of identifying all physicians having a significant role in the

care of the patient was expressed. It

was noted that asa matter of practice

some existing abstracting systems do

reflect the physician performing the

principal procedure, the assistingphysician for each set of procedures performed, each consultant rendering

a

formal consultation, and the referring

physician in those instances where this

physician may not have staff privileges. It was concluded by the Subcommittee that these are desirable options

but need not constitute basic data.

In these abstracting services, the detailed data are used primarily as a

basis fora report to the individual

physician concerning his activity for

the period of time reflected.

Flowever, the primary purposes for

collecting the data asa basic data item

are to examine patterns of use of

specific hospitals or specific services

withina hospital by specific physicians, and to have an individual identified to whom inquiries might be addressed for more detailed data as required. It was felt that for most purposes the two physicians identified

serve these needs and more detail

could be collected on an ad hoc basis

if desired.

The need fora unique number to identify specific physicians is obvious, and

the question arises as to whether such a number might not be community wide.

Abstracting systems which engage in

studies for their participating hospitals relating to patterns of care have

utilized portions of the number assigned to the individual physician to

designate specialty, status on the hospital staff, or other such information.

This is to permit review of patterns

of care related to these parameters

without the necessity of identifying any

individual physician except by his own

peers within his own setting. In general, attempts to do studies of individual physician differences have been

relatively unsuccessful because of the

small number of cases ofa particular

type any one physician may experience

during any meaningful period of time;

hence the utility of pattern review as a preferable device.

Similarly, practice patterns, i.e., the

use of particultw hospitals by indivi10
dual physicians holding multiple staff

appointments is information relatively

easy to obtain if the individual hospitals of an area have adequate data of

activity within their facilities.

The issue then resolved into the relative utility of recommending that all

hospitals of a given area replace their

existing numbers for each physician

with a community-wide number and

lose more in utility for one purpose

than might be gained for another.

The Subcommittee thus felt that at

this time it was preferable to concentrate on obtaining limited data in an

accurate fashion, i.e., precisely defined, and leave to future development

the matter of standardization of the

numbers used for this purpose.

11. Diagnoses. All diagnoses that affect the

current stay.

a. Principal Diagnosis is to be designated

and is defined as:

The condition established after study

to be chiefly responsible for occasioning the admission of the patient to the

hospital for care.

b. Other Diagnoses to be listed are:

All conditions that coexist at the time

of admission, or develop subsequently,

which affect the treatment received

and/or the length of stay. Diagnoses

that relate to an earlier episode which

have no bearing on this hospital stay

are to be excluded.

Comment: Of all the items in the data

set, the clear identification of diagnoses was considered of the greatest

iniportance. The Subcommittee reviewed current practices within hospitals, the various attempts to define

clearly what is meant by principal

diagnosis, qnd which other diagnoses

should be recorded. What has been

stated above represents the Subcommittee’s attempt to clarify in understandable terms the information considered essential.

Much consideration was given to the

recent development of problem oriented records as opposed to the diagnosis orientation on which most morbidity and mortality data are currently based. It was felt that as problem-orientation becomes more widespread and a standardized classification system is developed to reflect

this approach, it can be utilized as a

supplement to the diagnostic approach

now in widespread use.

The Subcommittee expressed much

concern over the multiplicity of coding systems for diagnosis that are

extant, and felt that while standardization is an essential requirement

for achieving comparability of data

it was beyond the scope of the Subcommittee’s charge to encompass the

problem caused by varieties of coding

systems. At the very least, however,

any coding system utilized to reflect

diagnosis should permit conversion of

the data into ICDA to enable analysis

on a comparable basis.

12. Pvoceduves and Dates.

a. All procedures performed in operating rooms are to be reported with

the dates, In addition to these procedures, all other significant procedures are to be recorded with the

dates. A significant procedure is one

which carries an operative or anesthetic risk or requires highly trained

personnel or special facilities or

equipment. Some examples of such

procedures are cardiocatheterization,

angiography, endoscopy, and supervoltage radiation therapy.

b. When more than one procedure is recorded the principal procedure is to

be designated. In determining which of

several procedures is the principal,

the following criteria apply:

.11
13.

(1)

(2)

The principal procedure is one

which was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary

to take care of a complication.

The principal procedure is that

procedure most related to the

principal diagnosis.

Comment: As is evidenced by the detail contained above, the Subcommittee

felt that precision in the definition of

this data item is an absolute necessity. The Subcommittee felt that all

procedures meeting the above definition should be an essential part of

any data set designed to reflect type

and volume of care received.

Several existing abstracting systems

are capable of providing the desired

detail currently, and the Subcommittee

feels that modifications should be made

in order that all have this capability.

As with diagnoses, it was felt that the

detail contained in the ICDAprocedure

codes is the standard that should be

used in describing the specific procedures performed.

Disposition of l%tient.

a.

b.

c.

d.

e.

Discharged to home (routine discharge).

Left against medical advice.

Discharged or transferred to another

institution.

Discharged or referred to an organized home care service.

Died.

Conznwzt: It has been traditional in

hospitals to distinguish the patient who

signed out against advice and those

patients who had died during the hospital stay from the routine discharge.

As hospitals developed home care

programs and a patient left the hospital for continued care in this type of

resource, it too was distinguished from

the routine discharge. In communities

where special services have been consolidated in a few hospitals, (e.g., neurosurgery centers, burn centers, etc.)

patients sent to this type of institution

were distinguished as well, and in hospitals having affiliated or related extended care facilities, the fact of trsnsfer became a routinely recorded and

hence an abstractable item.

Sentiment in favor of detailed data on

the specific institution to which the

patient was transferred was expressed

during the Subcommittee deliberations,

but it was felt that on an on-going basis,

data to permit an assessment of the

quantity of patients transferred would

suffice. In those hospitals showing unusual experience, an ad hoc study

could be performed in order to obtain

the desired detail.

Similarly, data on those deaths which

were the concern of the office of the

Medical Examiner or Coroner, and

the proportion of deceased patients on

whom a post mortem examination was

performed, while often collected routinely, did not seem to warrant inclusion in a basic data set.

Hence the Subcommittee arrived at

the items set forth, feeling that further

detail might be a local option or reserved for ad hoc studies of a shortterm nature.

14, Expected Principal Source of Paymant.

(Select one).

Self-pay

Workmen’s compensation

Medicare

Other Government payments (including CHAMPUS, Medicaid)

Blue Cross

Insurance companies

No charge (free, charity, special research, or teaching)

Other

12
Co?nment: For purposes other than

the processing of actual claims, andto

simplify analysis of hospital use, the

major categories of payment source

were considered adequate detail for

this information. It is recognized that

abstract data are derived from the

patients’ medical record, and that

more detaiI than set forth above would

require input from the business office

of the hospital before an abstract

could be completed. Thus, the Subcommittee limited its recommenda~on

of the basic data set to that information likely to be entered at the time of

admission, by way of a maxiifold admission sheet, and hence a routine

part of the medical record.

It was also recognized that in specific

localities, the “other” category may

assume special significance and a

further breakout of this category utilized to indicate organized prepaid

plans and the like. It did not appear

necessary, however, to include such

specification in the basic data set.

Model Form

It was not the purpose of the Subcommittee

to recommend a specific form on which to collect the data included in a basic data set. Existing abstract systems, reflecting local interests,

already collect substantially all the data included

within the basic data set, and include some optional data as well.

RECOMMENDED PROCEDURES

The Airlie House Conference report recommended that hospital discharge abstract systems

support the development of a systems approach to

providing information to multiple users bymeans

of single instruments (e.g., summary or face

sheets, claims forms, and discharge abstracts)

therefore reducing paperwork.

In approaching this problem, the objectives

have been to identify and define a minimum set

of demographic, diagnostic, and medical services

data on individual discharged hospital patients

which will serve basic institutional, community,

and research needs for data and together with

the necessary financial data satisfy the requirements for payment.

Virtually all hospitals currently operate a

separate business office and a medical record

department. As a consequence, information contained in the medical record is not readily available to the business office and hence not routinely

a part of the claim submitted to the third-party

payers.

The Subcommittee felt that when the medical

record department of a hospital is preparing an

abstract utilizing the basic data set a copy of

this abstract should be transmitted to the business office for combination with the patient’s

bill in order to support a claim for reimbursement by third-party payers. The Subcommittee

strongly recommends that hospitals develop procedures to accomplish this combination.

POTENTIAL FOR AREA, STATE,

AND NATIONAL HOSPITAL

PATlENT DATA SYSTEMS

The minimum basic data set for a uniform

hospital discharge abstract has been given field

trials in several local areas to determine the acceptability and the feasibility of recording the

data in varied hospital settings, and the quality

and usefulness of the results for the several purposes described earlier in this report. It is to be

expected that a suitable discharge abstract, coupled with a bill will be acceptable to the major

insurance carriers and will be widely adopted for

use in making payments for hospital care.

In areas where the uniform hospital discharge data set is abstracted by all or most hospitals a valuable set of records will be created.

Abstracts for individual patients can be used in

responding to requests by investigators in a .

variety of research areas. Hospitals with data

processing facilities should find the abstract,

alone or supplemented by other data, useful as

the basic record for a patient information system. The broader array of purposes-community planning, hospital administration, patient management, and research would be bet13
ter served when all hospitals in the area participate in a central abstract agency service.

These agencies exist at the present time

in only a few areas. Descriptions in the report

of the Conference on Hospital Discharge Abstract Systems indicate the variety of auspices

under which they are established and the services they provide. It is recommended that community health agencies in local areas—health

councils, comprehensive health planning agencies,

hospital councils —along with professional organizations explore the several approaches to

establishment of central abstract agencies and

select one best suited to the local situation.

The Subcommittee strongly recommends that

central abstract agencies adopt the minimum

basic data set and the definitions and classifications of individual data items. Aside from the

proven soundness of the data items, use of the

minimum basic data set unchanged as the core,

if not the totality, of a patient information system will provide data which can be compared

for different areas and will supply the building

blocks for a cooperative data system covering

regions, States, and even the Nation.

EXPANSION OF DATA SET TO

MEET SPECIAL NEEDS

As indicated in the comments on the individual data items recommended for the minimum

basic data set, in many instances supplementary

information may be highly desirable and accommodation of much of the additional information

being secured by existing abstracting systems

should be possible.

It was not the purpose of the Subcommittee

to recommend elimination of variation among existing abstracting systems since much of the variation evolved from experiences gained in performing a meaningful service. By taking into account

the variations known to exist, however, the basis

for past decisions were examined and where possible the “common denominators” identified.

It is hoped that there has been provided a

means by which data from a variety of sources

may be exchanged or pooled and permit analysis

with the confidence that similar categories and

definitions have been utilized regardless of

source.

Additions to the basic data set are to be expected. In some instances these have already

been pointed out, as in the case of the physicians

to be identified. The desirability of data on all

physicians having a significant role in the care

of a patient is not at all precluded by the recommendation that the basic data set include the attending physician and the physician performing

the principal procedure.

A brief review of items considered desirable as

1.

2.

3.

local options follows:

Source of Patient. For planning purposes

particularly, this might be a useful item.

At least one existing abstracting system

provides as an option to its participating hospitals the following categories for

this item:

a.

b.

c.

d.

e.

f.

g.

h.

Routine admission

Admission from ambulatory service or outpatient department

Admission from emergency service

Transfer from affiliated institution

Transfer from another hospital

Admitted for special service (not

transfer)

Readmission of patient previously

receiving care for current problem

Newborn within hospital.

Consultations. The number of consultations, the physician rendering this service, the time interval between admission

and consultation are all items which may

well have usefulness as local options.

Volume of Labovatovy or X-Ray Studies.

The detail with which such data may be

collected is virtually endless. In general,

it was the judgment of the Subcommittee

that other than those studies which were

classifiable as “procedures” as defined

above need not be considered as part of a

basic set. Both through departmental reports within hospitals or via the billing

procedures, data sufficient for most purposes may be readily obtained.

14
4.

.5.

6.

7.

Tissue Studies. Characterization of-the

tissue removed at a surgical procedure

may be of great usefulness for audit of

quality of care. A variety ofclassification schemes are available. An example

of one such is as follows:

;:

c.

d.

e.

f.

g.

None removed (e.g., repair)

Tissue removed for diagnostic

purposes

Normal tissue removed incidental

to primary purpose of procedure

Pathologic tissue removed confirmatory of preoperative diagnosis

Anticipated pathology not encountered, alternative pathologic” tissue removed

Anticipated pathology not encountered, normal tissue removed prophylactically

Pathologic tissue not removable,

palliative procedure performed:

Anesthesia. Type and duration of anesthesia are items often collected but not

considered data essential for a basic set.

Vaviution from Audit Cvitet+a. The multiplicity of possibilities of data useful in

auditing the services received by the patient within the hospital and the variations

in technique for conducting medical audit

by use of an abstracting service made it

impractical for a single recommendation

to be developed by the Subcommittee. Encouragement of local options in this area

to supplement the basic data set appeared

the most satisfactory manner in which to

resolve the issues involved. In the interest of practicality in obtaining data, and

economy in abs~acting, it was felt that

techniques involving minimal data collection have distinct advantages.

Blood Usage. In many abstract systems

the amount of blood tranfused is commonly recorded. These data are primarily

used to identify the one unit transfusion

and to demonstrate variation in blood

usage from

community.

hospital to hospital within a

While desirable as an option,

8.

9.

10.

11.

this information was not considered to be

an item for inclusion in the basic data set.

Natuve of Admission. (i.e., whether the

admission was an emergency or a previously scheduled admission.) While also

an item commonly collected, it did not

appear necessary for inclusion in basic

data set.

Serm”ce to Which Patient Was Admitted.

It is the practice in the larger hospitals

to classify in much deta:l the site within

the facility where care is rendered or the

department assuming primary responsibility for the care of the patient. ‘l%is is

usually done for internal administrative

purposes.

Some abstracting systems record the

service to which the patient was admitted

and have the further capability of reflecting transfers within the institution and allocation of time spent during a particular

admission among the respective units.

These are considered desirable options

but not at this time to be considered essential items for a basic data set.

Accommo&tion Within Hospital. Prior

to widespread third-par~ payment,

whether a patient occupied “ward,” or

“semiprivate” or “private” accommodations was considered an important item

and many abstracting systems continue to

collect this data. Variations in length of

stay by type of accommodation have been

noted.

More recent practices within hospitals,

resulting in placing patients in accommodations dictated by seriousness of illness rather than on a financial basis make

this item of little current interest.

Religion. During hospital care, especially with serious illness, when the clergy

may play a significant role in patient

management, it is necessary to know the

patients’ religion. In sectarian-sponsored

institutions the relative case load derived

from the major religious groups is of

frequent interest. As a consequence, some

15
12.

abstracting services offer this data item

as an option. It was the judgment of the

Subcommittee that it should remain so.

Living Awangements and Mavitul Stutus.

The Airlie House Conference suggested

these items receive consideration for

inclusion in the basic data set as affecting ease of discharge of specific patients.

Of the two items of information living

arrangements is the more pertinent to

this purpose but it isnot recorded by most

hospitals in a systematic, retrievable

manner.

Marital status is Iess suitable for the

stated purpose because it provides information only with respect to legal status

of the patient which differs from living

arrangement in many instances for many

different reasons. It was felt that an ad

hoc study on selected long-stay cases

would serve the purposes for which these

items might be desired.

13. Occupation. While occupation is often a

matter of interest, the precision required

for utility of data appeared to be impractical to expect from the admitting office

of the typical hospital.

Data are collected accurately on a routine basis if required for the management of the patient within the hospital or

for billing purposes. Occupation per se

does not meet this requirement. Place of

employment of the head of household is

likely to be collected, especially if thirdparty payment is related to employment,

but the utility of these data was considered too limited to warrant its inclusion

in a basic data set.

14. Addvess. The patient’s address was considered as a possible data item especially

for those urban areas where computerized conversion of address to census

tract or other small geographic units is

available. As indicated in the comment

on ZIP code (basic data item 5.), there

were a series of considerations which resulted in the recommendation of the Subcommittee that address not De a ~asic

data item. If, in specific localities facilities for address coding are available

and the matters of confidentiality and duplication can be adequately dealt with,

collection of this data item can be accomplished as a Iocal option.

15. l%ztientts Name. At no time was consideration given to inclusion of the name of

the patient in a basic data set. At least

one existing abstract system, however,

does provide for the collection of the

data for a single purpose only, i.e., in

order to prepare a report of activity

for the physicians in the participating

hospitals. This was desired in a specific community and in order to preserve

the confidentiality of the data, the abstracting system is considered to be an

extension of the hospital records depart.

ment and furnishes no data to any user

except with authorization from the par -

ticipating hospital. Other than for the

specific activity report referred to, the

patient’s name is omitted from the data

set subjected to analysis and not utilized

in any manner.

16. Chavges. The utility of this item in a

basic data set was the subject of considerable discussion by the Subcommittee,

with the ultimate decision reached that it

not be included as a basic data set item.

This was the only data item recommended

by the Airlie House Conference for consideration for the basic data set which is

not routinely available in the medical

records department of the typical hospital and which would, if included, duplicate the information available from the

projected concomitant billing form.

Since it was felt that a primary purpose

of the basic data set was to provide a

means by which to furnish accurate information to support a claim for payment,

which information would also have a number of other uses, the inclusion of the

total charge for the hospital stay on the

16
discharge abstract appeared to be anunnecessary duplication.

FUTURE REVISION

OF THE BASIC DATA SET

In both the comments accompanying the items

in the basic data set and the comment on local

options all the items given any consideration

have been set forth.

The only further comment necessary is that

the Subcommittee felt it had to deal with the here

and now in its judgments and that a process of

periodic reconsideration and revision needs to be

established. The Subcommittee has been informed

on the results of the field tests of the basic data

set and would expect to receive comments from

many quarters on the present report. It thus

recommends that it play a continuing role in

reevaluating its current judgments in the light

of both field experience and input from others

knowledgeable in the field.

REFERENCES

1Dorothy P. Rice and Barbara S, Cooper. Natiomd Health 5National Center for Health Statistics. Report of

Expenditures, 1929-71. Social Security Bulletin, January 1972. Twentieth Anniversary Conference of the U.S. National

2Hospital Discharge Data: Report of the Conference on Committee on Vital and Health Statistics.

Hospital Discharge Abstracts Systems. J. H. Murnaghan and K. 60p. cit., page 13.

L, White, Eds. hfedictd Care vol. 8, No. 4. (suppl.), 1970, 70p. cit., page 12.

30p. cit., page 10. ‘Op. cit., page 15.

40P. cit., page 23. 90p. cit., pages 14 and 15.

* U.S. GOVERNMENTPRINTINGOFFICE: 1976– 210.981:46

17
Series 1.

Sm”es 2.

Series 3.

Series 4.

Series 10.

Series 11.

Series 12.

VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES

Formerly .Public Health Service tiblication No. 1000

Programs and Collection Procedures. -Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and

other material necessary for understanding the data.

Data Evaluation and Methods Research. –Studies of new statistical methodology including experimental

tests of new survey methods, studies of vital statistics collection methods, new analytical techniques,

objective evaluations of reliability of collected data, contributions to statistical theory.

Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and health

statistics, carrying the analysis further than the expository types of reports in the other series.

Documents and Committee Reports. –Final reports of major committees concerned with vital and

health statistics, and documents such as recommended model vital registration laws and revised birth

and death certificates.

*

Data from the Health Interview Survey. –Statistics on illness; accidental injuries; disability; use of

hospital, medical, dental, and other services; and other health-related topics, based on data collected in

a continuing national household interview survey.

Data from the Health Examination Survey.–Data from direct examination, testing, and measurement

of national samples of the civilian, noninstitutionalized population provide the basis for two types of

reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and

the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without reference to an

explicit finite universe of persons.

Data from the Institutionalized Population Survey s.–Discontinued effective 1975. Future reports from

these surveys will be in Series 13.

Series 13. Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilities

providing long-term cue, ambulatory care, hospital care, and family planning services.

Series 14. Data on Health Resources: Manpower and Facilities. –Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health occupations, hospitals, nursing homes, and outpatient facilities.

Sert”es 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly

Sem-es 21

reports. Special analyses by cause of death, age, &d other demographic variables; geographic and time

series anafyses; and statistics on characteristics of deaths not available from the vital records, based on

sample surveys of those records.

Data on Natality, Marriage, and Divorce. -Various statistics on natality, marriage, and divorce other

than as included in reg&r annual or monthly reports. Special am+ ses by demographic variables;

. -.

geographic and time series analyses; studies of fertility; and statistics on characteristics of births not

available from the vital records, based on sample surveys of those records.

Series 22. Data from the National Mortality and Natality Surveys. –Discontinued effective 1975. Future reports

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Data from the National Survey of Family Growth. –Statistics on fertility, family formation and dissohstion, family planning, and related maternal and infant health toDics derived from a biennial survev of

. . -. .

a nationwide probability sample of ever-married women 1544 years of age.

For a list of titles of reports published in these series, write to: Scientific and Technical Information

National Center for Health Statistics

Public Health Service, HRA

Rockville, Md. 20852

,

Branch
U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

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