Analysis: Uniform Hospital Discharge Data Set

Uniform Hospital Discharge Data Set
Veronica Burgos
Kaplan University The year was 1969, when a conference was held by the National Center for Health Services Research and Development and Johns Hopkins to address hospital discharge abstract systems. A hospital discharge abstract system is an “abstraction of minimum data set from hospital charts for the purpose of producing summary statistics about hospitalized patients” (Porta, 2014). During that conference participants discussed the possibility of all short term general hospitals in the country start collecting a minimum set of patient specific data elements, which they referred to as the Uniform Hospital Discharge Data Set (UHDDS). UHDDS is used by acute care, short term and long term care hospitals to report inpatient data elements in a
standardized manner (HSS, 2006). It was applied in 1974 as the principle for collecting data to report to the Medicare and Medicaid programs. Other healthcare payers also use it for the uniform billing system. The purpose of UHDDS is to list and define a set of common, uniform data elements; those data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases (Sayles, 2014). The UHDDS data elements include: • Personal identification
• Date of birth
• Sex
• Race & ethnicity
• Residence
• Hospital identification
• Admission date
• Type of admission
• Discharge date
• Physician identification: attending & operating physicians
• Principal diagnosis
• Other diagnosis
• Qualifier for other diagnoses
• External cause of injury code
• Birth weight of neonate
• Procedure and dates
• Disposition of the patient
• Patient’s expected source of payment

UHDDS Data Elements
Data Element Definition/Descriptor

Personal Identification The unique number assigned to each patient within a hospital that distinguishes patient and his or her hospital record from all others in the institution

Race and Ethnicity a. Race
• American Indian/Eskimo/Aleut
• Asian or Pacific Islander
• Black
• White
• Other Race
• Unknown
b. Ethnicity
• Spanish origin/Hispanic
• Non-Spanish origin/Non-Hispanic
• Unknown

Hospital Identification A unique institutional number across data collection systems. The Medicare provider number is the preferred hospital identifier.

Physician Identification
• Attending Physician
• Operating Physician The Medicare unique physician identification number (UPIN) is the preferred method of identifying the attending physician and operating physician(s) because it is uniform across all data systems.

Qualifier for Other Diagnoses A qualifier is given for each diagnosis coded under “other diagnoses” to indicate whether the onset of the diagnosis preceded or followed admission to the hospital. The option “uncertain” is permitted.

Disposition of the Patient • Discharged to home (excludes those patients referred to home health service)
• Discharged to acute care hospital
• Discharged to nursing facility
• Discharged home to be under the care of a home health service (including a hospice)
• Discharged to other healthcare facility
• Left against medical advice
• Alive, other: or alive, not stated
• Died
Sayles, 2014 UHDDS data elements and definition/descriptor table
In 1983 when the Section 1886(d) of the Social Security Act was enacted, UHDDS data elements were included into the rules and regulations for implementing the inpatient prospective payment system based on diagnosis related groups.
Diagnosis related groups, or DRGs, are “groups of patients classified for measuring a medical facility's delivery of care. The classifications, used to determine Medicare payments for inpatient care, are based on primary and secondary diagnosis, primary and secondary procedures, age, and length of hospitalization” (Diagnosis, n.d.). The DRG classification system is widely utilized. One DRG is assigned to each inpatient stay. It also uses data elements of principal diagnosis, principal procedure, and other significant procedures into the DRG algorithms. That is why it depends on accurate selection and coding to report the elements correctly. In 1984 UHDDS was revised by NCVHS, with it later being adopted by the federal health programs in 1986. Currently, in addition to being used by hospital UHDDS can also be used with other organizations like rehabilitation facilities, nursing & retirement communities, and home health care
providers.

Reference
Diagnosis-related group [Def. 1]. (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved from http://medical-dictionary.thefreedictionary.com/diagnosis-related+group
HSS Inc. (2006). An Inpatient Prospective Payment System Overview: Diagnosis Related Groups. Retrieved from http://health-information.advanceweb.com/Article/An-Inpatient-Prospective-Payment-System-Overview-Diagnosis-Related-Groups.aspx
Porta, M. (2014). Hospital Discharge Abstract System [Def. 2]. In A Dictionary of Epidemiology (5th ed.). Retrieved from http://www.oxfordreference.com/view/10.1093/acref/9780195314496.001.0001/acref-9780195314496-e-945
Sayles, N. B. (2014). Health Information Management Technology: An Applied Approach. (pp. 146-148). Chicago, IL: American Health Information Management Association.