DOCUMENTS AND COMMITTEE REPORTS	 Series 4 

Number 19 

PROPERW OF THE “ 

PUBLICATIONS i3RANCH 

EDITORIALLIBRARY 

The Cooperative Health


Statistics System:


Its Mission and Program


Final Report from the


Task Force on Definitions


to the


Cooperative Health Statistics Advisory Committee


August 30,1976 

DHEW Publication’No. (HRA) 77-1456 

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

Public Health Service 

Health Resources Administration 

National Center for Health Statistics 

Rockville, Md. April 1977 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

Washington, D. C- 20402 

Stock No. 017-022+xwf4-l 
Library of CongressCataloging in Publication Data 

United States. Definitions Task Force. 

The cooperative health statistics system, its mission and program. 

(Vital and health statistics: Series 4, Documents and committee reports; no. 19) 

(DHEW publication; no. (HRA) 77-1456) 

1. Public health–United States–Statistical services. I. United States. National Center 

for Health Statistics. Cooperative Health Statistics Advisory Committee. II. Title. 111. Series: 

United States. National Center for Health Statistics. Vital and health statistics: Series 4, 

Documents and committee report; no. 19. IV. Series: United States. Dept. of Health, 

Education, and Welfare. DHEW publication; no. (HRA) 77-1456.


HA37.U1693 no. 19 [RA407.3] 312’.0973s 362.1’07’23


ISBN 0-8406-0092-5 77-608018

NATIONAL CENTER FOR HEALTH STATISTICS 

DOROTHY P. RICE. Director 

ROBERT A. ISRAEL, Deputy Director 

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

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

ELIJAH L. WHITE, Associate Directorforllzta Systems 

JAMES T. BAIRD, Ph.D., Acting Associate Director for International Statistics 

ROBERT C. HUBER, Associate Director for J4atzagement


MONROE G. SIRKEN, Ph. D., Associate Director for Mathematical Statistics


PETER L. HURLEY, Associate Directorfor Operations


JAMES M. ROBEY, Ph. D., Associate Director for Program Development 

PAUL E. LEAVERTON, Ph. D., Associate Director for Research 

ALICE HAYWOOD, Information Officer 

Vital and Health Statistics-Series 4-No. 19 

DHEW Publication No. (HRA) 77-1456 

Library of Congress Card Number 77-608018 
COOPERATIVE HEALTH STATISTICS ADVISORY COMMITTEE


CHAIRPERSON EXECUTIVE SECRETARY 

Dorothy P. Rice Gail F. Fisher


Director, National Center for Health Statistics Associate Director for the Cooperative


Health Resources Administration


5600 Fishers Lane


Rockville, Maryland 20857


Anita K, Bahn, M.D.


Professor of Community Medicine


University of Pennsylvania School


36th and Hamilton Walk


Philadelphia, Pennsylvania 19174


James L. Dallas


Statistics System 

National Center for Health Statistics 

Health Resources Administration 

5600 Fishers Lane 

Rockville, Maryland 20857 

MEMBERS 

Health 

1978 

1977 

1977 

of Medicine 

1979 

Chief, Office of Health Resources Development


Airdustrial Park


h4ail Stop 14-1


Olympia, Washington 98501


Donald J. Davids 1980


Chief, Records and Statistics Section and State


Registrar 

State Department of Health 

4210 East 1lth Avenue 

Denver, Colorado 80220 

PaLd M. Densen, SC.D. 

Director, Center for Community 

Medical Care 

Harvard Medical School 

643 Huntington Avenue 

Boston, Massachusetts 02115 

Clifton O. Dummett, D.D.S. 

1978 

Health and 

1979 

Professor and Chairman, Department of 

Community Oral Health and Preventive 

Dentistry 

University of Southern California 

Los Angeles, California 90007 

Frank E. Ellis, M.D.


Regional Health Administrator


Public Health Service


Region V


300 South Wacker Drive


Chicago, Illinois 60606


Eugene W. Fowinkle, M.D.


Commissioner, Tennessee Department of Public 

Health 

Cordell Hull Building 

Nashville, Tennessee 37219 

Symond R. Gottlieb 1980 

Executive Director, Greater Detroit Area 

Hospital Council, Inc. 

1900 Book Building 

Detroit, Michigan 48226 

Lillian Guralnick 1980 

Statistician, Dade-Monroe Professional 

Standards Review Organization 

2701 South Bayshore Drive 

Miami, Florida 33133 

Philip M. Hauser, Ph.D. 1978 

Professor of Sociology and Director, Research 

Center 

University of Chicago 

Chicago, Illinois 60637 

... 

Ill 
Lachlan L. Hyatt 1977 

Chairman, S.C. Governor’s Health Policy and 

Planning Council 

Edgar A. Brown Building 

Room 413 

Columbia, South Carolina 29201 

Vito M. Logrillo 1977


Director, Health Statistics


N.Y. State Department of Health


Empire State Plaza


Tower Building, Room 303


Albany, New York 12237


Mildred Mitchell-Bateman, M.D. 1977


Director, Department of Mental Health


State Capitol Building


Charleston, West Virginia 25305


Beverlee A. Myers 1978


Lecturer, Department of Medical Care


Organization 

School of Public Health 

University of Michigan 

Ann Arbor, Michigan 48104 

Aleda V. Roth


Director of Statistics


American Nursing Association


2420 Pershing Road


Kzmsas City, Missouri 64108


Margaret D. West


Route 8, Box 48


Annapolis, Maryland 21401


Martha R. Wilson, M.D.


Chief, Office of Program Development


Alaska Area Native Health Service


3rd and Gambell


P.O. Box 7-741


Anchorage, Alaska 99501


Karl D. Yordy


Senior Program Officer


Institute of Medicine


National Academy of Sciences


2102 Constitution Avenue


Washington, D.C, 20418


1980 

1978 

1979 

1979 
.: 

COOPERATIVE HEALTH STATISTICS ADVISORY COMMITTEE 

Task Force on Definitions 

MEMBERS 

Jtimes L. Dallas Margaret D. West 

Chief, Office of Health Resources Development Route 8, Box 48 

Department of Health and Social Services Annapolis, Maryland 21401 

Airdustrial Park, Mail Stop 14-1 

Olympia, Washington 98501 

Lachlan L. Hyatt Karl D. Yordy 

Chairman, South Carolina Governor’s Health Senior Program Officer, Institute of Medicine 

Policy and Planning Council National Academy of Sciences 

Edgar A. Brown Building, Room413 2102 Constitution Avenue 

Columbia, South Carolina 29201 Washington, D.C. 20418 

RESOURCE STAFF 

Gail F. Fisher James M. Robey, Ph.D. 

Associate Director, Cooperative Health Statistics Associate Director, Program Development 

System National Center for Health Statistics 

National Center for Health Statistics 5600 Fishers Lane 

5600 Fishers Lane Rockville, Maryland 20857 

Rockville, Maryland 20857 

v 
CONTENTS 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...


Le@Iation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


PublicLaw93-353 . . . . . . . . . . . .. ~~~~ ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


PublicLaw93-641 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Usersofthe System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


DataNeedsandSources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :::::


CooperativeHealthStatisticsSystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CooperativeSystemCharacteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Program Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..


EstablishedNeedforDataCoordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CoordinationandDecisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Transitional Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..


I 

1 

1 

2 

3 

3 

3 

5 

7 

7 

8 

8 

8 

14 

vi 
� 

THE COOPERATIVE HEALTH STATISTICS SYSTEM:


ITS MISSION AND PROGRAM


INTRODUCTION 

To plan and develop better health services, 

to deli;er those servic& in an effective and 

equitable manner, and to measure their effectiveness requires data on health status and 

trends, on the availability and utilization of 

health manpower, facilities and other resources, 

and on the costs of health services. 

Inadequate information in these areas causes 

major problems for data users. Data on resources 

and services lack uniformity, continuity, compatibility, and geographic detail. There are wide 

gtips in coverage. At the same time there is 

another serious problem. Multiple users of particular types of information are overwhelming 

individual practitioners and institutions with 

independent and duplicate demands for data. 

To meet problems such as these, Public Law 

93-353 authorized the National Center for 

Health Statistics to develop a cooperative health 

statistics system “to assist State and local health 

agencies and Federal agencies involved in matters relating to health, in the design and implemcnttition of a cooperative system.” The purpose of this legislation is to establish and 

maintain a coordinated and uniform data system 

to guide decisionmaking regarding health care in 

the United States, to enable them to make 

timely identification of health needs, to make 

better planning possible, and to allow more 

effective monitoring and evaluation of health 

pro~~ams and services. This will permit the 

health needs of the people to be met more 

adequately. 

LEGISLATION 

The Cooperative Health Statistics System 

operates under the specific legislative authority 

of the Health Services Research, Health Statistics, and Medical Libraries Act of 1974 (Public 

Law 93-353). The uses and purposes of the 

Cooperative Health Statistics System are further 

specified in the National Health Planning and 

Resources Development Act of 1974 (Public 

Law 93-641)–an example of how emerging 

programs are using a “data center” concept. 

Similarly, though less specifically, Professional 

Standards Review Organization legislation (Public Law 92-603, Section 249(f)) encourages the 

use of available data. 

Public Law 93-353 

The Health Services Research, Health Statistics, and Medical Libraries Act of 1974 (Public 

Law 93-353) authorizes the establishment and 

operation of the National Center for Health 

Statistics (NCHS). Establishing by statute what 

had been established administratively for several 

years, the law directs the Secretary of the 

Department of Health, Education, and Welfare 

to carry out specific functions through NCHS. 

Section 306(a) authorizes the Center to 

collect statistics on 

“(A)	 the extent and nature of illness and 

disability of the population of the 

United States . . . . 

“(B)	 the impact of the illness and disability 

of the population on the economy of 

the United States and on other aspects 

of the well-being of its population ..., 

“(c) environmental, social, and other health 

hazards, 

“(D) determinants of health, 

1

“(E) 

“(F) 

“(G) 

“(H) 

health resources, including physicians, 

dentists, nurses, and other health professionals . . . and the supply of services by hospitals . . . and other health 

institutions, 

utilization of health care . . . , 

health care costs and financing . . . . 

family formation, growth, and dissolution.” 

Section 306(d) of the law directs the Secretary, through NCHS, to “provide adequate 

technical assistance to assist State and local 

jurisdictions in the development of model laws 

dealing with issues of confidentiality and comparability of data.” 

Section 306(e) states that the National 

Center for Health Statistics will provide five 

services for the Secretary. They are to 

(1) 

(2) 

(3) 

(4) 

(5) 

assist State and local health agencies, and 

Federal agencies involved in matters relating to health, in the design and implementation of a cooperative system for 

producing comparable and uniform 

health information and statistics at the 

Federal, State, and local levels; 

coordinate the activities of such Federal 

agencies respecting the design and implementation of such cooperative system; 

undertake and support (by grant or 

contract ) research, development, demonstrations, and evaluations respecting such 

cooperative system; 

provide the Federal share of the data 

collection costs under such system; and 

review statistical activities of the Department of Health, Education, and Welfare 

to assure that they are consistent with 

such cooperative system. 

Section 306(f) directs NCHS to “cooperate 

and consult with (other) Federal departments or 

agencies and with State and local health departments and agencies, (and) to utilize, insofar as 

possible, the services or facilities of any agency 

of the Federal Government . . . of any appropriate State or other public agency and . . . of any 

private agency, organization, group, or individual, in accordance with written agreements 

between the head of such agency, organization, 

or group and the Secretary . . . (and with 

payment), if any, in such amounts as may be 

provided in such agreement.” 

Public Law 93-641 

The National Health Planning and Resources 

Development Act of 1974 (Public Law 93-641) 

authorizes the establishment and operation of 

health planning agencies at the local level (health 

systems agencies) and at the State level (State 

health planning and development agencies). 

Section 1511, Part B-Health Systems Agencies—establishes health service areas, each having 

a geographic region appropriate for the effective 

planning and development of health services. 

Under Section 1512, the Secretary of the 

Department of Health, Education, and Welfare is 

directed to establish a health systems agency for 

each health service area. These agencies may be a 

nonprofit private corporation, a public regional 

planning body, or a unit of a general local 

government. The purpose of these health systems agencies is to improve the health of 

residents in their areas by increasing the accessibility, acceptability, continuity, and quality of 

health services while restraining increases in the 

cost of health services and preventing unnecessary duplication of health resources. 

To meet these responsibilities, the health 

systems agencies are directed to assemble and 

analyze data concerning: 

“A.	 the status (and its determinants) of the 

health of the residents of its health 

service area, 

“B.	 the status of the health care delivery 

system in the area and the use of that 

system by the residents of the area, 

“c. the effect of the health delivery system 

on the health of the residents of the 

area, 

“D.	 the number, type, and location of the 

area’s health resources, including health 

services, manpower, and facilities, 

2 

9 
“E.	 the patterns of utilization of the area’s 

health resources, and 

“F. the environmental and occupational exposure factors affecting immediate and 

long-term health conditions.” 

The need for health planning agencies to 

utilize an existing mechanism for data collection 

and analysis rather than using their limited 

resources to duplicate a current system resulted 

in the regulation that health systems agencies 

coordinate their activities with the cooperative 

system provided for under Section 306(e) of 

Public Law 93-353. These agencies are also 

directed to refrain from undertaking the collection of data where adequate data are already 

collected by other entities—including those in 

the Cooperative System provided for under 

Section 306(e). When a health systems agency 

wishes to undertake the design, development, 

and operation of a new data system, whether 

directly or indirectly by using contractors or 

consultants, it must obtain the prior approval of 

the Secretary. Before making a decision, however, the Secretary must consult with the Statewide Health Coordinating Council, if any, for 

cuch State in which the agency’s health service 

area is Ioctited. 

In carrying out its responsibilities, the State 

planning agency must 

Provide for the coordination (in accordance 

with the regulations of the Secretary) with 

the cooperative system provided for under 

Section 306(e) of the activities of the State 

Agency for collection, retrieval, analysis, 

reporting, and publication of statistical and 

other information related to health care. 

(Section 1522 (a), (7), (A)) 

Part C–State Health Planning and Development —provides for the designation of State 

health planning and development agencies. Their 

functions include 

conducting the health planning activities of 

the State, including development of State 

plans to assist in the review of the State 

medical facilities plan, 

making findings on the need for new institutional health services, and 

determining the appropriateness of the services being offered. 

USERS OF THE SYSTEM 

Users of the Cooperative Health Statistics 

System include a wide range of public and 

private agencies, organizations, and individuals 

concerned with or involved in the planning, 

provision, regulation, or evaluation of health 

services and health resources at the national, 

State, and local levels. 

Federal users of the data generated by the 

Cooperative System include the Health Resources Administration, National Institutes of 

Health, Alcohol, Drug Abuse, and Mental Health 

Administration, Social Security Administration, 

Health Services Administration, Center for Disease Control, U.S. Bureau of the Census, other 

agencies, and the Congress. The roles of some of 

these users will be noted in following pages. 

Official State and local agency data users 

include those concerned with the direct provision of care, with planning, and with licensing, 

rate-setting, certificate of need, and other regulatory activities, as well as those concerned with 

population growth and change. These agencies 

include health, welfare, and human resources 

departments, State planning agencies and health 

systems agencies, third-party payers, fiscal intermediaries, professional standards review organizations, departments of education, higher 

education councils, and employment services. 

Professional organizations–particularly those 

concerned with the health professions and health 

facilities and health researchers–also use the 

Cooperative Health Statistics System. 

DATA NEEDS AND SOURCES 

Needs 

“Health statistics production in this country 

presents a picture of uncoordinated data collection, aggregation, presentation and analysis 

among various Federal, State, local, and nongovernmental sources. The separate efforts 

underway are frequently duplicative of one 

another and despite common goals, possess little 

3 
of the continuity, compatibility and standardization which are essential to a reliable health 

statistics system . . . . 

“This situation will be intensified by the 

increasing number of new Federal programs 

planned or in operation for quality assurance, 

cost control, resource planning, health insurance, and service delivery systems . . . . 

“The need for formal mechanisms for reaching basic decisions regarding cooperative efforts 

between agencies in the development and support of statistical systems is clearly indicated.”l 

Needs for health data range from patient 

management decisions to the establishment of 

national health policy. To meet these needs of 

its users, the Cooperative Health Statistics System should be able to provide current national, 

State, and local data that have uniform definitions in the areas of 

Health status, 

Resources of health manpower, facilities, 

and services, 

Utilization of health services and facilities, 

Expenditures and sources of funds for health 

services and for the development of health 

resources, and 

Environmental, social, and other health 

hazards. 

Data available for these areas are widely 

varied in coverage, completeness, uniformity, 

and usefulness. They are available, if at all, in 

piecemeal fashion, from a variety of sources. 

The Cooperative Health Statistics System, 

seeking to identify data components which can 

provide a considerable part of the needed 

information, has cooperated with producers and 

users of data to develop minimum essential data 

sets for certain components. 

Responding to the growing public responsibilities related to the planning, provision, and 

evaluation of health services, the Assistant Secretary for Health has established a Health Data 

Policy Committee. Composed of representatives 

1Department of Health, Education, and Welfare: 

Health Statistics Plan. Fiscal Years 1976-1977. Public 

Health Service. Washington. U.S. Government Printing 

Office. Nov. 1975. 

from the Public Health Service agencies, the 

Social Security Administration, and the Social 

and Rehabilitation Service, the Committee 

advises him on important policy issues concerning the collection and analysis of health and 

he~lth-related statistics throughout the Department: and assists him in coordinating the 

Department’s health data requirement. In this 

capacity, the Committee has prepared iI Health 

Statistics Plan2 which reviews the present situation on health statistics production, identifies 

the Department’s current health statistics activities, and identifies some of the major gaps. It 

found that 

“The existing general purpose health-related 

statistics programs of the Department of 

Health, Education, and Welfare, despite the 

high quality of many of the individual 

segments, as a whole are inadequate . . . ,“ 

Putting stress on the problem of geographic 

specificity of data, the Committee said that 

The most significant challenge in the field of 

health statistics is the development of data 

systems that are capable of satisfying the 

multiple needs for data at the regional, 

State, and local levels and other geogmphic 

aggregations, and that provide the types of 

data needed for evaluation of the impact of 

major Federal health programs. 

Reliable, timely, pertinent, and comparable 

health data and analysis are needed at all 

levels which will describe the health status of 

the population, the availability of resources, 

the accessibility of services, the costs of 

services and resources, the sources of funding, the utilization of present services, and 

the quality of care. Without such statistics, 

the capacity at every level of the health 

industry to plan, manage, and evaluate our 

tremendous investment in health resources 

and delivery systems is severely limited. 

Existing general purpose data systems do 

not, in general, provide data in enough 

geographic detail to be of maximum use to 

even the Federal level consumers, much less 

the State and local users. 

21bid. 

4 
Sources 

Data on health status, resources, and services 

come from a wide variety of sources. For some 

arms the sources are excellent; for others they 

tire multiple but still inadequate. For still others, 

there is virtually no way to get usable information, 

Basic to all health and health services data is 

information on the size, character, and growth 

of the population. This comes from decennial 

und supplemental censuses conducted by the 

U.S. Bureau of the Census and from birth, 

death, marriage, and divorce records. The collection, analysis, and publication of vital statistics 

from the latter has long been a responsibility of 

the States and of the National Center for Health 

Statistics, Birth and death data are now collected routinely, with standardized basic data 

sets, by all States, and are transmitted to the 

National Center for Health Statistics for further 

processing, analysis, and publication. Although 

there is still need for improvement, reasonably 

current data from this Cooperative System 

component are available for the Nation, for most 

States, and for many smaller geographic areas. 

This is the element of greatest coverage and 

accuracy in the Cooperative System. 

Health status. –Information on health status 

is derived from birth and death reports and from 

a vm-iety of other sources which provide 

inforrnat ion cm, or clues to, some aspect of 

hculth status. The most comprehensive information on health status comes from the Health and 

Nutrition Examination Survey of the National 

Center for Health Statistics. This provides 

national and regional data but is too complex 

:md expensive for routine use at a State or local 

level. 

For some years the National Center for 

Heidth Statistics has also conducted the Health 

Intc-rvimv Survey-a periodic sample survey providinq national and regional estimates for a 

vwic~y of measures of disability and of utilization of health services. Valuable as these surveys 

:trc, they have inherent limitations since they 

provide only indirect indicators of health status 

such its conditions, disabilities, and impairments 

us perceived by the individual or by a family 

member. 

Tu incrcasc the usefulness of the Health 

Intm-view Survey to the States and to smaller 

geographic areas, there are now plans to redesign 

the sample and quadruple its size. Within several 

years this should include 160,000 households, 

making possible estimates of health status and 

health service utilization for smaller areas. At 

the same time, it will allow selective sample size 

increases for States desiring to fund more 

detailed surveys. Technical assistance will be 

provided to State and local areas wishing to 

collect such data from households. 

Health manpo wer.–Sources of health manpower data include both public agencies, particularly the States in carrying out their licensure 

and other regulatory responsibilities, and private 

agencies and organizations representing individual health professions. Professional organizations 

such as those of physicians, dentists, and nurses 

collect and publish national and State inventory 

data covering members of their professions. 

However, data from these sources range widely 

in completeness and in comparability. Definitions, even of the persons included in total 

counts, are not uniform or precise. There is also 

little information available about the rapidly 

proliferating new health occupations. 

Under the Cooperative System, more detailed statistics are now being collected for 13 

occupations. The National Center for Health 

Statistics, for instance, compiled considerable 

national and State data on the numbers, distribution, and characteristics of members of many 

health professions and is publishing this information in an annual publication. 

Health facilities.–The situation of facility 

statistics is similar to health manpower statistics 

since State public agencies develop data in 

connection with licensing, certificate of need, 

and other responsibilities, while the American 

Hospital Association and State and local hospital 

associations also collect and publish data to 

meet their various needs. 

To eliminate some of this duplication, the 

American Hospital Association and the National 

Center for Health Statistics began, in 1968, to 

pool their resources. The result is the yearly 

publication of the Annual Survey of Hospitals. 

Today the American Hospital Association, with 

NCHS support, surveys their registered hospitals, 

while other institutions are surveyed by the 

Center. NCHS also maintains a Master Facilities 

Inventory which includes not only hospitals but 

also nursing homes and other inpatient health 

5 
facilities. Data on mental hospitals and other 

mental health facilities, collected jointly by the 

National Institute of Mental Health and NCHS, 

are also incorporated in the Master Facilities 

Inventory. 

Inadequacies of the data now available include incomplete coverage of all types of facilities (specifically outpatient facilities), inadequate classification of facilities, and inadequate 

data on funding and staffing. 

Inpatient care. – For some years the National 

Center for Health Statistics has conducted the 

Hospital Discharge Study, a national sample 

survey on hospital utilization. Other data collection efforts now under way include those related 

to Medicare, Medicaid, professional standards 

review organizations, and private organizations 

such as the Commission on Professional Hospital 

Activities. Data on the utilization of mental 

hospitals are collected routinely by the National 

Institute of Mental Health. Of all these efforts, 

only the NCHS Hospital Discharge Study provides a national picture. The other data collection efforts, serving a particular purpose with 

respect to selected patients (such as Medicare) or 

institutions (such as the Commission on Professional and Hospital Activities), cannot meet the 

needs of public agencies looking for an understanding of the total hospital care situation. 

Under the Cooperative Health Statistics System, 

developmental projects are funded in selected 

States to obtain hospital care data representative 

of the services provided to the total population. 

Much worse is the data available on services 

provided by nursing homes and other extended 

care facilities. The National Center for Health 

Statistics has collected nursing home facility and 

patient data on a periodic basis, but the analysis 

is mainly for national purposes and has limited 

use on a State or local level. 

Ambulatory care. –Data on care given in 

physicians’ offices, group practice settings, public health clinics, hospital emergency room and 

outpatient services, and telephone consultations 

are similarly limited. The National Center for 

Health Statistics now conducts the National 

Ambulatory Medical Care Survey which provides 

nationaI data on some of these ambulatory care 

elements. Expansion of this survey to meet State 

purposes is being tested. 

Expenditures, costs, prices, and financing.– 

There is need for better national, State, and 

regional information on total expenditures and 

on sources of financing in relation to family 

composition, socioeconomic characteristics, and 

insurance coverage. This is probably the area for 

which the greatest interest exists today, and the 

one for which available data sources are the least 

adequate. Data are needed not only for costs 

and prices of services provided by traditional 

methods and under traditional systems but also 

on the newer types of health service organizations such as group practices and health maintenance organizations, particularly on costs of 

services in relation to organization, utilization, 

staffing, and methods of payment and financing. 

There is almost no information on costs of 

treatment and costs of hospitalization in relation 

to diagnosis and outcome. 

Data to meet these needs must be assembled 

from many sources, including the recipients of 

services (through such mechanisms as the Health 

Interview Survey), from institutions providing 

care, from noninstitutional providers, and from 

third-party payers. 

Environmental, social, and other health 

hazards. –The past few decades have witnessed 

great changes in the physical and chemical 

contaminants of man’s environment and an 

increasing recognition of the impact of both the 

physical and social environment on the health of 

man. Consultants to the United States National 

Committee on Vital and Health Statistics have 

been asked to prepare recommendations about 

statistical data bearing on health effects of the 

environment which should be collected, ways in 

which they should be collected, and changes 

which should be made in existing measures of 

environmental factors in order to better relate 

environmental factors to the health effects. 

Although present sources are inadequate in 

providing needed data, there are sources now 

available which could be used more fully and 

effectively. These include: 

Death reports-data on occupation and on 

cause of death, including cancer by site, 

respiratory disease, heart disease, accidental 

death; 

Hospital discharge data; and 

Health Interview Survey and Health and 

Nutrition Examination Survey-data on acci6 
dents, injuries, nutritional status, and other 

characteristics. 

COOPERATIVE HEALTH STATISTICS 

SYSTEM 

In response to the need for more adequate 

health-related data to meet national, State, and 

local needs, the National Center for Health 

Statistics, in 1970, began work looking to the 

establishment of a Cooperative Health Statistics 

System- Since that time needs have been identified with more precision; high-priority data 

components have been identified; certain data 

sets have been established; and the Cooperative 

System is now being placed in operation with 

the cooperation of public health and statistical 

agencies, professional groups, and other private 

organizations. 

Vital statistics data, provided by the States 

to the National Center for Health Statistics, are 

now a basic component of the Cooperative 

System. As NCHS decentralizes responsibility 

for collecting data on health manpower and 

facilities from the Federal to the State level, the 

States’ role in the Cooperative System will 

increase proportionately. In the area of utilization data–particularly hospital discharge data– 

the change from a national sample to State and 

local level collection is more difficult. For 

certain other data areas, there is the possibility 

that methods developed in national sample 

surveys will be expanded and translated into a 

Sttite setting. 

There are, however, certain data collection 

efforts of the National Center for Health Statistics which do not lend themselves, because of 

their complexity and cost, to such decentralization. The Health and Nutrition Examination 

Survey and the Health Interview Survey, for 

instance, must continue as direct national 

efforts, although the Health Interview Survey 

protocols can be used on an ad hoc basis to meet 

needs in some States and large metropolitan 

iikTM, 

Cooperative System Characteristics 

. ... . .. . . . ..” .,, ,

When tully dWfdOped tne bystem wm nave 

the following characte~istics: 

It will provide national, State, and local 

aqencim and organizations with comparable 

data on vital events, health manpower and 

facilities, utilization and financing of health 

services, and related elements. 

It will play the lead role in coordinating 

national, State, and local health data systems, to the end that there will be maximum 

comparability y, completeness, accuracy, and 

timeliness and that unnecessary duplication 

will be eliminated. 

It will be the primary mechanism by which 

the Federal Government closes the gap in its 

health statistics system and seeks to avoid 

duplication. 

It will meet the data needs of a wide range 

of users of health data and will provide 

analytical and technical assistance to make 

the data useful. 

It will preserve the required and proper 

confidentiality of data in shared systems. 

It will be responsible for providing mechanisms for collecting quality data in requisite 

geographical detail. Data collection will conform to a set of minimum requirements 

adopted by the Department of Health, Education, and Welfare after consultation with 

State and local governments and health 

organizations in the private sector. These 

requirements will include use of minimum 

data sets and uniform definitions, classifications, and quality standards. 

It will carry a continuing responsibility for 

research and study of health data needs and 

for developing methods and mechanisms to 

meet such needs. 

It will have, in each State, a health statistics 

center or focus that is a public agency or a 

nongovernmental entity officially designated 

by the governor or the appropriate State 

public agency or official in ageement with 

the National Center for Health Statistics and 

with major producers of the data. 

It will have, in each State center, the 

capacity for data analysis and will prepare 

and disseminate analyses on a regular and 

timely basis. 

It will have funds for the maintenance of the 

System, which are provided by the members 

7 
of the cooperators with the System, on a 

fair-share cost basis. 

Program Development 

In 1971, research and development leading 

to the establishment of the Cooperative System 

was initiated by the National Center for Health 

Statistics in cooperation with the National Center for Health Services Research. First steps 

included examining alternatives for content, 

structure, and methods. This examination identified data eIements of highest priority and sought 

to develop the highest possible level of compatibility in data handling techniques with similar 

activities in other parts of the Department, the 

U.S. Bureau of the Census, and other agencies. 

From this work emerged comparable definitions, 

standards, and procedures for the collection, 

processing, analysis, and presentation of data. 

Close-working relationships with national and 

State agencies, and with other data producers 

and users, also emerged as the Cooperative 

System was developed. 

Established Need for Data Coordination 

The great increase in the concern of the 

Federal Government with respect to the planning, provision, and assessment of health 

resources and health services has called for a 

corresponding need for and collection of healthrelated data. Federal concern, financial support, 

and data collection efforts reIated to the supply 

of health facilities and health manpower go back 

for many years, particularly in relation to the 

Hill-Burton hospital construction legislation and 

to the series of health manpower resources laws. 

Legislation supporting Medicare, Medicaid, and 

maternal and child health services has also given 

the Federal Government a major role in paying 

for health services and responsibility for assessing that care. The new health planning legislation has broadened and reinforced these Federal 

concerns. 

The effects of these Federal responsibilities 

have resulted in a sharp growth in needs for data 

to plan, administer, and evaluate health service 

and health resource programs and a proliferation 

of often duplicated reporting requirements with 

consequent burdens on State agencies and cm 

health service institutions. 

As a result of the problems arising from this 

Proliferation, the Department’s Health Data 

policy Committee has decided that the CooDem- ~ 

tive Health Statistics System will play the’ lead 

role in coordinating Federal, State, and loca 

health data systems. A number of mechanisms 

have been developed to enable the System to 

meet such responsibilities. 

Coordination and Decisionmaking 

The Cooperative Health Statistics System is 

being developed under a policy of maximum 

participation in decisionmaking by data producers and users. The mechanisms include use of 

advisory committees, formal and informal agreements, and working arrangements with other 

Federal agencies, with State and local agencies, 

and with professional organizations. 

Advisory committees.–One of these mechanisms, the Cooperative Health Statistics 

Advisory Committee, was established in 1974 by 

the Secretary of the Department of Health, 

Education, and Welfare to advise, consult with, 

and make recommendations to the Secretary 

and to the Director of NCHS on general program 

policy and plans for research, development, and 

implement ation of the Cooperative Health 

Statistics System. In this capacity, the Advisory 

Committee assures that national, State, and local 

agencies are appropriately involved in the 

Cooperative System and develops appropriate 

uniform standards on the content, definitions, 

data sets, and methodology used by the Cooperative System. The Committee also oversees the 

review, endorsement, and promulgation of 

national standard data sets in the areas of 

hospital, ambulatory, and long-term health care; 

the effective and efficient operation of the 

System; and the recommendation of temporary 

Technical Consultant Panels to investigate 

assigned technical problems. 

Members of the Committee include the 

Director of the National Center for Health 

Statistics, who serves as Chairman, and 18 

members appointed by the Chairman. Members 

are nationally recognized scientists such as 

demographers: bio~tatisticians, sociologists, 

economists, and political scientists. They are 

8 
I


selected for their competence, interest, and 

perspective in the area of health care delivery 

system data needs. Other providers and users of 

health data are also on the Committee. They 

include executives of State and local health 

departments, leaders in local health planning 

agencies, representatives of interested national 

organizations, and leaders in other Federal statistical agencies. 

Another decisionmaking mechanism, the 

United States National Committee on Vital and 

Health Statistics, has authority, under Public 

Law 93-353, to assist and advise the Secretary of 

the Department of Health, Education, and Welfare on matters related to the National Center 

for Health Statistics. This Committee coordinates statistical data activities within the Department and establishes and updates minimum data 

sets. The Committee has also established Technical Consultant Panels to develop recommendations on such data sets for action by the 

Committee. 

Data coordination among Federal agencies.– 

In accordance with the requirement of Public 

LaJv 93-641, the National Center for Health 

Statistics and the Bureau of Health Planning and 

Resources Development have reached an agreement on implementation of health data activities. This includes provisions for 

Definition of data needs and standards 

development, 

Operational responsibility and maintenance 

of quality control, 

Technical assistance and training, and 

Research and development in data utilization, 

This agreement emphasizes the primary responsibility of the National Center for Health 

Statistics and assigns managerial authority for 

st;itistical activities to the Center. 

The Federal and State governments as well 

M other agencies need hospital utilization data 

on the total population serviced, including 

specific data on patients for whom Federal 

payments funds are used. These statistics help 

miccrtain the proficiency of patient managermmt, program management, evaluation, and 

rcscmch programs. 

However, the development of cooperative 

relationships and procedures with common 

access to hospital discharge data ii hampered by 

many problems arising from the confidential 

nature of the records, because of the need for 

speed in meeting the needs of some of the users, 

and because of the multiple vested interests in 

these data. 

Its professional standards review organizations make the Social Security Administration 

one of the most important agencies in need of 

these discharge records. Authorized in 1972 

under the Social Secunt y Administration 

amendments, these organizations involve practicing physicians in the review and evaluation of 

health care services covered under the Medicare, 

Medicaid, and maternal and child health 

programs. They are responsible for assuring that 

health care paid for under these programs is 

medically necessary and consistent with professionally recognized standards of care and with 

encouraging use of less costly sites and modes of 

treatment where medically appropriate. The 

professional standards review organizations are 

required to collect discharge data on their 

covered patients and to review services furnished 

in and by hospitals and other health care 

institutions. They may also review other types 

of health care, such as ambulatory and long-term 

care. 

The Social Security Administration is also a 

major source of data on health expenditures at 

the national and State level. The Cooperative 

Health Statistics System, in cooperation with 

the Social Security Administration and the 

Health Services Administration’s Bureau of 

Quality Assurance, is developing data systems 

which will respond to utilization of services 

information. 

For many years the Public Health Service has 

also been concerned with the nation’s supply of 

and need for health manpower. There have been 

a variety of cooperative and contractual 

relationships with professional organizations and 

other agencies to secure health manpower data 

necessary in seeking solutions. Increasingly, 

however, the Federal responsibility is focusing 

on the Health Resource Administration’s Bureau 

of Health Manpower and National Center for 

Health Statistics, who work closely with health 

9 
professions organizations. Agreements with 

these organizations have taken a number of 

forms, including the purchase of data tapes and 

contractual relationships for the conduct of 

health manpower inventories. For several of 

these professions, NCHS has also conducted 

surveys to establish or update professional 

inventories. In November 1974, the responsibility for obtaining information on the current 

supply of health manpower through national 

inventories was transferred from the Bureau of 

Health Manpower to the National Center for 

Health Statistics. 

Paralleling these efforts in the past few years 

has been the development and implementation 

of the manpower statistics component of the 

Cooperative Health Statistics System. The 

States’ increased need for such data resulted in 

the Cooperative System being given the primary 

Public Health Service responsibility. Agreements 

have been reached that lean toward establishing 

uniform data content, definitions and standards, 

and making the States the primary data 

collectors. There are now 13 health occupations 

for which the participating States are collecting 

and processing data for the Cooperative System. 

These are doctors of medicine, doctors of 

osteopathy, dentists, pharmacists, optometrists, 

registered nurses, licensed practical nurses, 

dental hygienists, physicaJ therapists, nursing 

home administrators, chiropractors, podiatrists, 

and veterinarians. 

In addition to these health manpower 

statistics, State and local government agencies, 

through their mental health organizations, have 

an increasing need for statistical data to 

facilitate patient care, utilization review, program planning, budgeting, and monitoring and 

evaluation. The Health Planning Act and the 

Community Mental Health Centers Act are also 

increasing the demand for such data. 

In response to these needs, the Alcohol, 

Drug Abuse, and Mental Health Administration 

Statistical Plan has proposed a Mental Health 

Statistics Improvement Program for their 

National Institute of Mental Health. If utilized, 

this program would bring State and local mental 

health agencies up to a minimum standard level 

of statistical reporting to meet both the needs 

for program management and the baseline 

statistics requirements of the Coopemtive 

System. A National Institute of Mental Health 

and National Center for Health Statistics 

Coordinating Group has been established to 

develop a plan and to identify areas in which the 

two organizations can work together through 

the Cooperative HeaIth Statistics System. 

In addition to health manpower and mentul 

health statistics, data are also needed on 

nationally notifiable diseases and immunizations. The Center for Disease Control (CDC), 

responsible for controlling infectious and other 

preventable diseases and conditions, collects and 

publishes data on these diseases and immuniztitions and conducts surveillance of infectious 

diseases, other preventable conditions such as 

vector-borne and dental diseases, occupational 

health and safety problems and certain CIIVirL)llmentally induced health problems—on a national 

level as well as for subareas. These data comprise 

the only uniform statistics on morbidity 

available at the local level for all jurisdictions in 

the Nation. 

Until recently, national statistics on legal 

abortions were collected by the Center for 

Disease Control and published in an annual 

Abortion Surveillance Report. In 1974, 51 

States and the District of Columbiti provided 

partial or complete information. It was ah~ccd 

by the Center for Disease Control and the 

National Center for Health Statistics that 

reporting of national baseline abortion statistics 

is logically the responsibility of the National 

Center for Health Statistics. The States should 

begin reporting such data to NCHS rather than 

to CDC as soon as they are able to meet the 

reporting standards established by NCHS. 

The National Center for Health Statistics has 

developed reporting standards for legal abortions. States meeting these standards are 

reporting to the National Center for Health 

Statistics as part of the vital statistics component of the Cooperative Health Statistics 

System. As the level of performance for a 

particular State meets the National Center for 

Health Statistics standards, reports formerly 

made available to the Center for Disease Control 

will be transferred to NCHS. 

Data components. –Seven data areas were 

originally identified as necessary components of 

10

the Cooperative Health Statistics System. They 

arc vital statistics, health manpower statistics, 

health facilities statistics, hospital care statistics, 

long-term care statistics, ambulatory care statistics, and health interview statistics. Work was 

subsequently undertaken to establish minimum 

essential data sets for these areas, with four 

areas—vital statistics, health manpower statistics, 

health facilities statistics, and hospital care 

statistics—selected for first priority. 

Research and development grants were made 

to develop procedures and to test data sets in 

these components. Mechanisms used include 

Advisory and technicaJ committees, including the Technical Consultant Panels established by the United States National 

Committee on Vital and Health Statistics. 

.ld hoc task forces to develop and evaluate 

initial data sets. 

Pilot testing. 

Potential data producers and users review 

and comment, and national and regional 

workshops. 

Data sets for one of the seven data 

components—vital statistics—have been established for some time and are revised over a cycle 

of 8 to 10 years. To meet their legal 

responsibilities, States routinely collect information on birth, death, marriage, and divorce 

statistics and have for many years provided 

NCHS with microfilm copies of birth and death 

certificates , and for most States marriage and 

divorce records. States funded under the vital 

statistics component of the Cooperative System 

provide these data to the Center on tapes 

according to uniform standards. Another data 

activity in this component—abortion reporting— 

~vill soon be initiated in a few States. The vital 

statistics system, with its close working relationships between the States and the National 

Center for Health Statistics, has served as a 

model for the Cooperative System. 

Another of the data ~omponents–manpower 

statistics—focuses on obtaining basic information on the numbers, characteristics, and 

geogmphic distribution of health manpower in 

the 13 health occupations licensed in all or 

nearly all States and to furnish a frame for 

special surveys. A uniform minimum data set for 

all occupations was developed by the National 

Center for Health Statistics in consultation with 

other producers and users of health manpower 

data. As experience is gained in applying this 

uniform minimum data set, it will be reviewed 

and modified for specific information needs 

about each occupation. 

The first stage of development by the 

participating States established rosters of at least 

7 of the 13 occupations licensed in 49 or more 

States. These occupations are chiropractors, 

dental hygienists, dentists, doctors of medicine 

and osteopathy, registered nurses, licensed 

practical or vocational nurses, nursing home 

administrateors, optometrists, pharmacists, physical therapists, podiatrists, and veterinarians. 

The second stage instituted surveys connected to the State licensure renewal procedure, 

utilizing the minimum data set. A future 

expansion will extend coverage to all health 

manpower, both licensed and unlicensed. The 

National Center for Health Statistics will be 

responsible for unduplicating, for the States, 

persons licensed in more than one State. 

Minimum data sets on a third data 

component—statistics on hospitals, nursing 

homes, and other inpatient facilities–have been 

developed by NCHS. These sets, which closely 

parallel those used to collect national data for 

the Master Facility Inventory, will be reviewed 

periodically by the United States National 

Committee on Vital and Health Statistics. 

Participating States usually obtain this data 

through State licensing or other regulatory 

procedures. 

The minimum data set for the fourth 

component—hospital care—is known as the 

Uniform Hospital Discharge Data Set; it was 

developed by the U.S. Committee on Vital and 

Health Statistics. The Cooperative System’s 

complex problems with this data set arise 

primarily from 

Competing and often conflicting needs for 

hospital care data for Medicare, utilization 

review, pro fessional standards review organizations, health planning, and statistical and 

other purposes. 

11

Processing problems of meeting timeliness 

needs.. 

Increasing problems of protecting an individual’s personal privacy. 

These and related problems are now under 

study by a Technical Consultant Panel of the 

United States National Committee on Vital and 

Health Statistics. A data set for long-term care, a 

fifth data component, has been developed and is 

under review by the United States National 

Committee on Vital and Health Statistics. 

Although ambulatory care statistics, the 

sixth data component, have not yet received 

emphasis in the Cooperative System, the 

methods of the NCHS National Ambulatory 

Medical Care Survey are being adapted by some 

States to meet State and local data needs. A 

minimum data set for ambulatory care, developed by the United States National Committee 

on Vital and Health Statistics, is now being 

tested under an NCHS contract. 

A similar situation exists with health 

interview statistics, the seventh component. The 

National Center for Health Statistics is developing a package survey which can be used by 

States or localities in making their own health 

interview surveys. It is not planned, however, 

that such surveys will reduce the need for, or 

replace, the National Health Interview Survey. 

The plan for enlarging this survey’s sample, 

to provide estimates for smaller geographic 

areas, has already been noted. 

The seven components originally defined for 

the Cooperative System do not include all the 

health data needs. Lacking, for example, are 

services provided by such entities as health 

departments, health care expenditures and 

financing, and environmental and social hazards. 

These topics will be discussed in connection 

with problems and priorities of the System. 

State Cooperative System operations. – 

Forty-five States, at the end of September 1976, 

had one or more components of the Cooperative 

Health Statistics System in an active or 

developing stage. Of these 45 States, 14 had 

considerable coordinative activity, usually in the 

form of a State health statistics center. Such a 

center is usually found in the health department 

of the State government; but coordinating 

activities are administered in a few States by 

State human resources departments, planning 

agencies, the Office of the Governor, or by 

nongovernmental agencies. 

The Cooperative Health Statistics System 

requires this network of State centers to serve as 

focal points to insure that health statistical data 

will be assembled and analyzed. Such centers 

might have a direct responsibility y for primary 

data collection and activities of one or more of 

the Cooperative System components, or might 

serve as the lead agency or coordinator for data 

collected by other agencies. The State center 

might also process such data or might contract 

for processing by another agency. The center 

would make such data tapes and other output 

available to users when appropriate. 

These centers should have the capacity to 

analyze health-related data. They should also bc 

able to provide consultation to planning agencies 

and other data users on the interpretation, 

limitations, and potentialities of available data 

and to advise on needs for additional information and ways in which it can be secured. 

These centers might be part of a public 

agency, such as the State health department, or 

might represent a consortium of data producers 

and users. 

At the present time there is no clear 

designation of, or mechanism for the designation 

of, these centers. At the same time there is some 

urgency for making some designations, both for 

legal purposes (Health Planning and Resources 

Development Act, Public Law 93-641 ) and for 

furtherance of the development of the Cooperative System. 

To assure that such centers receive proper 

recognition and support, it is essential that they 

be designated by the State governor or other 

appropriate public official who can insure that 

public, private, and voluntary interests have 

been considered, that legal sufficiency exists, 

and that the public interest will be served. 

Criteria for a State Health Statistics Center 

should include: 

1.	 Commitment to the System’s principles, 

with evidence of interest and leadership 

in meeting needs for reliable, timely, and 

comprehensive data on health status, 

12

2. 

3. 

4. 

5. 

6, 

7. 

resources, utilization of services, and 

expenditures; 

Current activities which include the 

collection, or the coordination of collection, of some of the established data sets 

in tit al records, health facilities, health 

manpower, and/or hospital discharges, 

under minimum statistical standards 

established by the Cooperative System, 

and conformance to uniform procedures 

for coding and processing information; 

Use of statistical methods which are 

found to be acceptable by independent 

peer groups; 

Evidence that the agency or organization 

does, or is willing to, guarantee to 

provide equal access to the data it 

collects to other members of the 

Cooperative System and other appropriate users, with access limited only by the 

provision of guarantees by the recipients 

of nondisclosure of privileged information; 

Evidence of analytical ability which will 

result in coordination and assessment of 

data from the several components, for 

purposes of planning and decisionmaking; 

Establishment of plans and priorities for 

future expansion of coverage of data 

components; 

Indication of coordination of data 

collection and analysis efforts within the 

State–such as the establishment and 

active role of a board, advisory committee, or other organized group which 

includes major data producers and users. 

When an application for acceptance as the 

Stitt~ center is received from an organization in 

any State, the System should review the 

application with these criteria. If satisfied that 

sLIch a designation is in the best interests of the 

St~te and the Cooperative System, it may enter 

into a written agreement with the organization 

to that effect. There may also be a financial 

contractual arrangement, but this is not to be 

considered as essential for such designation. 

Technical cooperation and assistance. –The 

participants in the Cooperative System–both 

public agencies and private organizations— 

receive technical and financial assistance and 

support from the NationaI Center for Health 

Statistics. 

Cooperative System participants have the 

opportunity to share in the development and 

review of uniform minimum data sets in 

health-related areas. They also have the opportunity to assemble data for their own jurisdictions or areas of concern with some assurance of 

completeness, quality, timeliness, and comparability with data similarly assembled for other 

jurisdictions and subject matter areas. 

In addition, they can receive technical 

assistance as resources permit. The National 

Center for Health Statistics has instituted this 

program of continuing communication to 

provide information sharing, including workshops on program issues, among all participants. 

A data application and research focal point, 

established within the National Center for 

Health Statistics, plans to develop the capacity 

to develop, test, and demonstrate the application of special tabulations and analysis of data 

generated by the Cooperative System. This 

entity will also carry out special research and 

development in the problem-oriented analysis of 

data for local planning purposes. The identification of subject areas and actual problems will be 

accomplished through a continuing exchange 

with local and State health planners, managers, 

demographers, and regulatory agencies as well as 

the National Center for Health Statistics and 

other Federal organizations. The solutions 

would be provided through a mix of State, local, 

and Center staff and outside contractors. 

The methodologies developed as a result of 

this activity will be given to users in the form of 

technical assistance, the National Center for 

Health Statistics training program, or direct 

exchange with the initiating agency or planner. 

Participants in the Cooperative System will 

be able to take advantage of specialized training 

opportunities for their staff members, thereby 

assisting them in improving their data analysis 

ability. The training program now includes the 

short courses offered through the National 

Center for Health Statistics Applied Statistics 

13 
Training Institute and work sessions to address 

technical concerns. 

The Cooperative Health Statistics System 

also provides financial support, usually under 

contract on a cost-sharing basis, for developmental, operational, and program coordination 

activities related to the Cooperative System. 

Until recently, this support has been on a 

component-by-component basis, and principally 

for four components–vital statistics, health 

manpower, health facilities, and hospital care. 

Each contract has been monitored separately by 

a project officer with an appropriate technical 

background. 

It has become apparent, however, that this 

method made no provision for coordination of 

the individual components toward the interrelationships necessary to a total health information 

system. Accordingly, in several States,. the 

scopes of work have now been designed to 

develop and demonstrate the feasibility of 

coordinating the various component activities 

within the State. 

The concept of coordination is necessary to 

establish a single viable State system. There are 

two major benefits in developing a policy of 

multicomponent single contracts. First, it would 

provide for coordination of individual components toward the interrelationships necessary to 

a total health information system. And second, 

it would give the States flexibility in disbursing 

funds among components. Inherent in the 

current system is the lack of any provision 

which would allow a State to begin the 

development of components of the Cooperative 

Health Statistics System without the negotiation 

of an additional single contract. 

Under the provisions of a single multicomponent contract, a modification to the 

scope of work and additional funds could 

provide for the initial planning and development 

of another component. It could also result in 

more economical use of staff and funds in the 

States since it would permit much more flexible 

use of resources. 

This new funding approach would encourage 

the merger of research and development of data 

systems activities, with a focal point in each 

State which coordinates its activities with the 

National Center for Health Statistics. In 

summary, it should make possible the development of meaningful State health statistics 

centers. 

Transitional Phase 

Today the Cooperative Health Statistics 

System is in a transitional phase; new systems 

are being developed as existing systems ad~pt to 

expanded sources which can more directly 

provide health data to multiple users at State 

and local levels. 

There are a number of programs now in 

operation which collect data similar to those 

collected under the Cooperative Health Statistics 

System. In the area of health manpower, several 

health professional associations conduct periodic 

inventories-several of them with support from 

the National Center for Health Statistics. In the 

area of health facilities, the American Hospital 

Association makes an Annual SLlrvcy of 

Hospitals, with some support from the National 

Center for Health Statistics. The National Center 

for Health Statistics concurrently conducts 

activities related to the Master Facility Inventory. Hospital care data are also collected as a 

national sample through the Hospital Discharge 

Survey conducted by NCHS. 

The National Center for Health Statistics 

will continue to seek the cooperation of private 

organizations collecting data similar to those 

being collected in a Cooperative System 

component—particularly with the goal of minimizing the burden on respondents caused by 

duplicate inquiries. However, where such organizations do not meet the goal of providing data 

responsive to the needs of multiple users at 

national, State, and local levels, the National 

Center for Health Statistics will develop and 

implement components of the Cooperative 

Health Statistics System to meet those needs. A 

certain amount of duplication is probably 

necessary, and in some cases important, for 

reasons of access or timeliness. In most 

instances, however, it is too burdensome and 

expensive and should be minimized as rapidly as 

possible. 

To that end, the National Center for Health 

Statistics and health manpower professional 

associations are collaborating to provide national 

inventory data on manpower without duplica14

tion of data collection. These professional 

associations obtain data through the State 

Iicensure process for States not funded through 

the Cooperative Health Statistics System. These 

data, together with data from the Cooperative 

Health Statistics System funded States, provide 

the basis for national figures on the health 

profession. 

Problems.-In recent years a complex of 

reIated and partially conflicting principles and 

doctrines on confidentiality y, freedom of 

information, and invasion of privacy have 

received extensive attention. The c&fide”ntialit y 

of data is critical to society’s wise handling of 

information. Yet there exists nothing that 

approaches a satisfactory synthesis of decisions 

in this area as it relates to a cooperative 

Federal-State-local system of health statistics.3 

The Bureau of the Census, the U.S. Bureau of 

Labor Statistics, the National Center for Health 

Statistics, and certain other Federal agencies 

have traditionally given assurances of confidentialityy. 

The competing doctrines–the value of such 

assurances of confidentiality, the principle of 

freedom of information, the economy of using 

the same data by more than one agency for 

more than one purpose, and the conflict 

between “need to know” and “right to 

pnvacy’’–constitute the central problem. The 

economy aspect is one of the key reasons for 

building a cooperative statistical system among 

local, State, and Federal agencies in the health 

field. Yet operating agencies, especially at the 

State and local levels, need to use specific data 

for various administrative purposes. These data, 

often identifying individuals or business establishments, complicate the maintenance of 

confidential handling by statistical agencies of 

the same or allied data. 

There must be an appropriate balance 

between a person’s right to personal privacy and 

society’s need for information about itself in 

order to control its activities. This principle is 

consistent with the basic objective of the 

Cooperative Health Statistics System. Today 

Federal law recognizes the concept of protected 

data and gives adequate protection to data 

‘Ibid, 

acquired by the National Center for Health 

Statistics when the providers have been given 

assurances of confidentiality. 

Yet resolution of the more complex 

problems that arise with the growth of, and 

multiple use of, the data generated and 

processed through the Cooperative System 

requires the drafting and adoption of a model 

State law which can serve as both a starting 

point and a coordinating influence on an 

emerging body of State law and regulations. 

Another problem to be solved is the gaps in 

data elements. The Cooperative Health Statistics 

System began developmental work and operation with the identification of seven data 

components, related primarily to health status, 

health resources, and utilization of health 

services, with at least several of the data 

components contributing to knowledge in more 

than one of these areas. There are, however, 

additional areas in which basic work must be 

undertaken. These include the provision of 

health services in settings other than those 

included in the established data sets, costs and 

financing of health services, and the impact of 

environmental and social hazards to health. 

Present data sets do not permit a comprehensive 

analysis of the relationship between organizations and individuals providing health services 

and the health of the population to be 

served-particularly their patterns of utilizing 

services, their health problems, and their changes 

in health status. The pattern of inpatient, 

ambulatory, and community services received by 

an individuzd from a single organization or from 

several providers, including public agencies, 

cannot be identified, nor can services provided 

be linked to needs of the population. 

Cost and expenditures data now come from 

a variety of sources, all piecemeal and impossible 

to put together. Yet, as the cost of health 

services increases, and seems likely to increase 

sharply in the near future, the need for 

comprehensive data in this area is becoming 

more urgent. 

Even less work has been done in the 

development of data on environmental and 

social hazards from the perspective of public 

health. Yet much could be done in this area, 

even now, by an appropriate analysis of available 
data on health status, hospitalization, and deaths 

from conditions already known to have a large 

component of environmental onset or development. 

Cost sharing is another problem that needs 

to be solved since a fundamental principle of the 

Cooperative Health Statistics System has been 

that its costs should be shared on an equitable 

basis by participating agencies and organizations. 

During the period of program initiation and 

testing, the National Center for Health Statistics 

provided funding through contracts for the 

development, evaluation, and programs established for the collection, processing, and analysis 

of data. Now, there are States which receive 

some funding through this contract mechanism. 

Additionally, the States have for many years 

received nominal payment, on a record unit 

basis, for vital record data transmitted to the 

National Center for Health Statistics. 

As the Cooperative System grows, there is an 

urgent need to cope with the problems of cost 

sharing. For this reason, the Cooperative Health 

Statistics Advisory Committee has established a 

Cost-Sharing Task Force which studies these 

problems. This Task Force has developed 

preliminary guidelines for cost sharing for the 

vital records and is now working on similar 

guidelines for other components. The Task 

Force notes, however, that other types of 

problems must be faced. These include 

Cost-sharing guidelines for States wanting to 

negotiate a single contract to implement several components and combine the staff and 

other resources. 

Payment when State systems are being used 

to meet other Federal data needs, such as 

health systems agencies’ requirements, which 

result in an enlargement of the record or 

expansion of work beyond the Cooperative 

Health Statistics System requirements. 

Cost-sharing guidelines when the partner is 

an organization or agency other than the 

State government. 

To respond to the mandate of Congressional 

legislation and to meet urgent needs for data 

to plan and evaluate various Federal health 

programs, the Federal agencies must work more 

closelv with States to develop the Cooperative 

System. Since the technical d&elopmen~ of this 

System is ahead of the resources needed for 

implementation, the program will require a 

sharp increase in funding over the next few 

years. 

l%mities. –Although it may be impossible to 

rank the present and future needs for system 

development and operation, two immediate 

priorities are 

Development of an adequate financing 

structure which includes mechanisms and 

guarantees of appropriate funding by transfer of funds among the programs of the 

Department of HeaIth, Education, and 

Welfare to assure that Departmental agencies 

benefiting from the Cooperative System 

provide their fair share of the operating costs. 

Development of State health statistics 

centers with general responsibility for the 

development, integration, and analysis of 

health-related data from the Cooperative 

System’s data components and from other 

appropriate sources. Because the output of 

these State centers will be important in 

public decisionmaking, there are advantages 

to having the control at the State level in a 

public agency. It may be appropriate, in 

some States, for such centers to make 

subcontracts with other organizations or 

data brokers. However, this should be done 

with the objective of strengthening the 

concept of a State health statistics center. 

It is apparent that a successful system 

cannot emerge from the independent growth of 

area or subject matter components, no matter 

how well-designed and executed they may be. 

Of overriding importance is the establishment of 

State centers that will give a purpose, a focus, a 

direction, and an integration of the Cooperative 

System. 

A principal objective of the Cooperative 

System is helping States to bring together a 

body of information with which they can meet 

their planning, regulatory, and other needs. If 

this were not the case, sample studies would 

suffice for most national statistical purposes. 

16

It is of primary importance, therefore, to 

help States to identify their needs and to make 

the best use of available data to meet present 

urgent needs. Even if all of the seven identified 

components were neatly in place, the needs of 

the States would not be met. The States, 

therefore, must view these components as 

“helps” in meeting their needs and not entirely 

as “ends” in themselves. Priorities in developing 

component areas are also of importance. 

Vital statistics must be given precedence 

since they are not only basic to planning and 

problem identification in the States, but State 

activity in this area is essential for national use. 

Data on resources, both facilities and 

manpower, should be placed next in priority. 

Data on the location and types of services 

provided by hospitals and other health care 

facilities is essential for planning and for 

regulation. Similar data on &her L&e facilities 

are almost as important. 

Utilization of hospitals and other facilities is 

also an area of high priority. Several States are 

conducting developmental and demonstration 

activities in three utilization components— 

hospital care , ambtdatory care, and long-term 

care. Other States are fostering coordination 

among data collectors and users in their State 

and are encouraging the development of a consortium of such interests. However, organization 

roles at the Federal level need to be resolved and 

lines of technical cooperation must be further 

defined before there can be a rapid implementation in this area of urgent data needs. 

o 00 
Series 1.€

Scrl”cs 2.€

Series 3.€

Swim 4.€

Series 10.€

Series 11.€

VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES 

Formerly Public Health Seruice Publication 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. h~ethods 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 certiilcates, 

Data j70m 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 poptdation 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. 

Series 12. Data from the Institutionalized Population Surveys. –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 care, 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 

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

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

sample surveys of those records. 

Sert”es 21. Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce other 

than as included in regulas annual or monthly reports. Special analyses 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. 

Sert”es 22. Data j?om 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. 

Sert”es23. Data j?om the National Survey of Family Growth. –Statistics on fertility, family formation and dissolution, family planning, and related maternal and infant health topics derived from a biennial survey of 

a nationwide probability sample of ever-ma.miedwomen 1544 years of age. 

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

National Center for Health Statistics 

Public Health Service, HRA 

Rockville, Md. 20857