Hospital Morbidity Data System

Transcription

1 Hospital Morbidity Data System HMDS REFERENCE MANUAL JULY 2014 Inpatient Data Collections Data Integrity Directorate Performance Activity and Quality Division

2 SECTION 1 INTRODUCTION

3 HOSPITAL MORBIDITY DATA SYSTEM OVERVIEW The Hospital Morbidity Data System (HMDS) is one of the largest of data collections managed by Western Australian Health (WA Health). The data collection is comprised of over 22,000,000 electronic inpatient records dating back to The number of records added to the collection increases every year in line with population growth. There were approximately 1,200,000 separations (records) added to the collection for 2013/2014. In accordance with the National Health Information Agreement, WA Health, as are all State and Territories, are mandated to provide an annual submission to the Australian Institute of Health and Welfare (AIHW) of all admitted activity information for the State. In turn, under Part IIIC of the Hospital and Health Services Act 1927, WA Health mandates all public and private hospitals to submit complete, accurate and timely admitted activity data to the HMDS in accordance with agreed data management protocols. For each record there are more than 200 data elements captured. The majority of these data elements correspond to National Minimum Data Set (NMDS) requirements and are based on the National Health Data Dictionary (NHDD) as defined by the AIHW. PURPOSE OF THE COLLECTION The HMDS provides WA Health with the necessary information for planning, allocating and evaluating health services within Western Australia. Some of the other key purposes of the collection include provision of information for: Mandatory reporting to the Commonwealth in accordance with national agreements e.g. National Health Care Agreement Monitoring and assessing state health service utilisation (public and private) Strategic planning, resource allocation and performance measurement of all levels of health care Health service funding and resource allocation Epidemiological and medical research Data linkage INPATIENT DATA COLLECTIONS UNIT The HMDS is maintained by Inpatient Data Collections (IDC) Unit within the Performance Activity and Quality Division (PAQ). To ensure that HMDS remains valuable and relevant, IDC is responsible for: Providing support to data entry and maintenance of data entry packages in private hospitals Enforcing data quality and providing data quality education Clinical coding education Responding to regular and ad hoc data requests Supporting data users internal and external to WA Health Developing analytical tools Maintaining metadata

4 UNIT OF MEASUREMENT The unit of measurement with the HMDS is an episode of care. An episode of care starts with a formal admission to hospital and ends with a formal discharge or separation from hospital. HMDS INCLUSIONS The HMDS includes all episodes of care that occur in the following West Australian health services: Public acute hospitals Public psychiatric hospitals Private acute hospitals (licensed by WA Health) Private psychiatric hospitals (licensed by WA Health) Private day surgeries (licensed by WA Health) HMDS EXCLUSIONS The HMDS does not include episodes of care (or equivalent unit of measurement) pertaining to: Patients attending outpatient or community health services Patients in private residential aged care facilities Patients in community residential care facilities Patients treated in Defence Force health services Still births All reporting health services should ensure that any data reported to the HMDS complies with the above inclusions and exclusions. DEVELOPMENT OF HMDS The HMDS is subject to continual review to ensure that all data is relevant, measurable, of reasonable quality and is able to meet state and national reporting requirements. Changes may be applied to the collection at the beginning of the financial year in response to version changes and/or state or national mandates. For 2014/2015 the following changes have been made: Application of new Australian Refined Diagnosis Related Group (AR-DRG_ version 7.0) Addition of a new data items: Medicare Number; Medicare Person Identification Number Updates to the HMDS Interface File Specification Addition of new Edits: 851 Medicare no not in correct format 852 Medicare person number not in correct format Medicare person number present Medicare number is not Medicare number is invalid number Medicare person number blank but Medicare number is not An involuntary patient has a leave period in excess of 28 days An external cause code may be reported (refers to diagnosis codes D59.6, D61.2, D64.2, D68.3, D69.5 & G25.6 where there are some exceptions that don t require an external cause code to be reported) Age at admission is less than 1 year of age and no admission weight recorded Infant weight is only reportable for patients less than 1 year of age The reported admission weight is outside the expected range for the patient

5 HMDS REFERENCE MANUAL The manual provides direction and guidelines for hospitals regarding the submission of data and the definitions of required data items. The appendices in the HMDS Reference Manual include provision of further information on data values for certain data items such as language, country of birth and establishment lists. Updated reference tables (such as Establishment Lists) are also uploaded to the Morbidity intranet throughout the year for public hospitals to access. ABBREVIATIONS Abbreviation ABF ABS ACAT ACHI ACHS ACS AHPRA AIHW AR-DRG ARDT BIPAP CCU COF CPAP DG DoHA DRG DVA Definition Activity Based Funding Australian Bureau of Statistics Aged Care Assessment Team Australian Classification of Health Interventions Australian Council of Health Care Standards Australian Coding Standards Australian Health Practitioner Regulation Agency Australian Institute of Health and Welfare Australian Refined Diagnosis Related Groups Admission, Readmission, Discharge and Transfer Policy for WA Health Services Bi-Level Positive Airway Pressure Critical Care Unit Condition Onset Flag Continuous Positive Airways Pressure Director General Department of Health and Ageing Diagnosis Related Group Department of Veterans Affairs

6 FSH FTP HA22 Form HCARe HDU HITH HMDC HMDS HSA ICD-10-AM ICD-9-CM ICECI ICU IDC IPPB KPI MBRN MDC METeOR MPS NCCC NCCH nfd NHDD NHTP NMDS OD OSQH PAQ Fiona Stanley Hospital File Transfer Protocol Hospital Admission 22 Form Health Care and Related Information System Client Management System High Dependency Unit Hospital In The Home Hospital Morbidity Data Collection Hospital Morbidity Data System Hospital Services Arrangement International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification International Classification of Diseases, 9th Revision, Clinical Modification International Classification of External Causes of Injury Intensive Care Unit Inpatient Data Collections Intermittent Positive Pressure Breathing Key Performance Indicator Medical Board Registration Number Major Diagnostic Category Metadata Online Repository, Australian Institute of Health and Welfare Multi Purpose Service National Casemix and Classification Centre National Centre for Classification in Health Not further defined National Health Data Dictionary Nursing Home Type Patient National Minimum Data Set Operational Directive Office of Safety and Quality in Healthcare Performance Activity and Quality Division

7 RITH TMS TOPAS UMRN URN Rehabilitation In The Home Theatre Management System The Open Patient Administration System Unit Medical Record Number Unit Record Number

8 KEY TERMINOLOGY The following provides definitions of a number of key terms frequently used in the HMDS to classify a particular type of patient or administrative process. You will find reference to these key terms throughout this Manual. Boarder A boarder is a person who is receiving food and/or accommodation but for whom the hospital does not accept responsibility for treatment and/or care. Boarders can include: Family members of an admitted child who are provided with accommodation. Healthy newborn babies who are more than 9 days old, not requiring acute care and belonging to a mother who is currently admitted to the hospital. Healthy newborn babies who are more than 9 days old, not requiring acute care and belonging to a mother who is transferred to another hospital. Technically, Boarders are not admitted to hospital, however the hospital is permitted to register them. Boarders are not reported to the Commonwealth. Episode of Care An episode of care refers to the period of treatment or care given to a patient from the point of admission to the point of separation from hospital. A patient may be seen and/or treated in outpatients or emergency immediately prior to admission, however for the purposes of the admitted activity data collection, this does not constitute part of the episode of care. An episode of care commences with a formal admission to hospital and ends with a formal separation from hospital. Formal Admission A formal admission is an administrative process that initiates the record of the patient's treatment and accommodation within a hospital. A formal admission represents the start of an episode of care. Statistical Admission A statistical admission is an administrative process that occurs within an episode of care and captures the commencement of a particular type of care (Care Type). A single episode of care can have multiple statistical admissions if a patient s Care Type changes numerous times within the episode of care. Formal Separation A formal separation/discharge is an administrative process that ceases the record of the patient's treatment and accommodation within a hospital. A formal separation represents the end of a patient s episode of care.

9 Statistical Separation A statistical separation/discharge is an administrative process that occurs within an episode of care and captures the end date the patient received a particular type of care (Care Type). A single episode of care can have multiple statistical separations if a patient s Care Type changes numerous times within the episode of care. Figure 1: Types of Admissions and Separations demonstrates how a single episode of care commencing with a formal admission to hospital and ending with a formal separation can be divided by statistical admissions and separations to capture periods of care under particular Care Types: Care Type = Acute Care Type = Maintenance Care Care Type = Acute Care Type= Maintenance Care Statistical Admission Statistical Admission Statistical Admission Formal Admission Statistical Separation Statistical Separation Statistical Separation Formal Separation Figure 1: Types of Admissions and Separations Overnight Patient An Overnight patient is a patient who is admitted to the hospital where the intention (on admission) is that they will stay a minimum of one night in hospital. The actual duration of the patient s episode of admitted care has no bearing on the patient s status as an overnight patient. For example: A patient is admitted at 22:00pm with the intention on admission that they will remain an inpatient overnight, but they are subsequently discharged at 23:30pm. This patient would still be considered Overnight because the intention was to admit the patient overnight. Same-Day Patient A Same-Day patient (sometimes referred to as Day only ) is a patient who is admitted to a hospital with the intention (on admission) that they will be discharged on the same-day that they are admitted (e.g. Admission Date and Separation Date are the same).

10 Qualified Newborns A newborn is a child who is aged 9 days or less. A newborn is deemed a Qualified Newborn if they meet at least one of the following criteria: Is the second or subsequent live born infant of a multiple birth, whose mother is currently an admitted patient; AND/OR Is admitted to a Level 2 (L2) Nursery of Neonatal Intensive Care Unit (NICU), approved by the Commonwealth Health Minister for the purpose of the provision of special care. (Admission to a L2 Nursery or NICU is based on the requirement to receive this level of care, not because of bed availability); AND/OR Remains in hospital without its mother; OR Is admitted to the hospital without its mother. At 10 days of age or any day after, a patient must meet the acute admission criteria to stay admitted with a Care Type of Newborn. If the patient meets the criteria of an acute admission and was born during the admission, the Patient Type should be Qualified at 10 days of age and the Care Type remains as Newborn. The patient remains as Qualified Newborn until they no longer meet the acute admission criteria. When the patient stops meeting the criteria a statistical type change is performed to an appropriate Care Type. If a patient is admitted at 10 days of age or older and admitted from home or another facility and meets the admission criteria for an acute admission, the Care Type should be Acute and the Patient Type should be admitted. For further information refer to Section 6 Data Element Definitions, Client Status. Unqualified Newborns A newborn is a child who is aged 9 days or less. A newborn is deemed an Unqualified Newborn if they meet at least one of the following criteria: Is a single live birth or the first live born infant in a multiple birth, whose mother is currently an admitted patient; AND/OR Is not admitted to an intensive care facility in a hospital, being a facility approved by the Commonwealth Health Minister for the purpose of the provision of special care. If an unqualified newborn remains in hospital after day 9, the newborn then becomes a Boarder patient and a statistical discharge must be performed to change the patient s Care Type and Client Status. Unqualified newborns do not require any active treatment or intervention. And because of this, unqualified newborns are not included in the Medicare Agreement or eligible for health insurance benefits. Any funding requirements for an unqualified newborn is already catered for in the funding for the mother s inpatient stay. For further information refer to Section 6 Data Element Definitions, Client Status.

11 SECTION 2 CONTACT DETAILS

12 CONTACT DETAILS INPATIENT DATA COLLECTIONS Manager, Inpatient Data Collections Ph: (08) Data submission Ph: (08) Ph: (08) Ph: (08) HMDS data quality and edit queries **If you are a private site and have a renewed licence to operate issued for 2014/15, data submissions should be made via MyFT (see web address to register below) Please contact Manager, Inpatient Data Collections above if you are having difficulties registering or require more information. Ph: (08) Ph: (08) Ph: (08) hmds.edits@health.wa.gov.au Coding queries Ph: (08) coding.query@health.wa.gov.au Coder education and training Ph: (08) clinical.coding@health.wa.gov.au Data extracts Ph: (08) Ad hoc data requests Ph: (08) KEY WEBSITES STATE WA Health Coding in W.A. HMDS Reference Manual Operational Directives/Information Circulars Activity Based Funding (Western Australia)

13 Health Information Network TOPAS and HCARe Client Management System Support Web page: NATIONAL National Casemix and Classification Centre (NCCC) ICD-10-AM (Australian Modification) 8th Edition Books Australian Refined Diagnosis Related Groups (Versions 5.1 to 6.0) Definitions Manual Casemix and Clinical Coding Specialty Booklets The online ordering is at the link below: Web page: Australian Consortium for Classification Development (ACCD) The NCCC will continue to manage the sale and distribution of the above publications via their online ordering system. All other support and services are handled by the National Centre for Classification in Health Australian Consortium for Classification Development (ACCD). ACCD Web page: Telephone: (02) Web page: Mailing Address: c/o National Centre for Classification in Health Faculty of Health Sciences Cumberland Campus C43T The University of Sydney PO Box 170 Lidcombe NSW 1825 AUSTRALIA Independent Hospital Pricing Authority Information on Activity Based Funding may be obtained from: Web page: Telephone: (02) Facsimile: (02) Australian Institute of Health and Welfare METeOR (Metadata Online Repository) National Health Data Dictionary (NHDD) Australian Hospital Statistics These and other publications/resources may be accessed from: Web page: Australia Post The latest suburb to postcode mappings may be searched or freely downloaded from: Web page: Please note: The Inpatient Data Collection (IDC) downloads the Australia Post postcode list on an annual basis and updates HMDS as required. The updates are then provided to the hospitals so that their information systems may be updated to reflect the current values.

14 Australian Health Practitioner Regulation Agency Clinician Medical Board Registration Numbers (MBRNs), Podiatrist registration numbers and Dental Clinician registration numbers are maintained by the Australian Health Practitioner Regulation Agency. Scala House 11 Torrens Street Braddon ACT 2612 AHPRA GPO Box 9958 Perth WA 6001 Web page: Telephone:

15 SECTION 3 HOSPITAL RESPONSIBILITIES

16 HOSPITAL RESPONSIBILITIES This section provides instructions and guidelines for the submission of data for both private and public hospitals. This includes a list of relevant operational directives, reporting schedules, and information on the validation of episode of care in edit. ALL HOSPITALS OPERATIONAL DIRECTIVES The Performance Activity and Quality (PAQ) Division of WA Health produces Operational Directives (OD) that provide instructions to all hospitals concerning definitions, reporting time frames for public hospitals and instructions for submitting data to the HMDS. The most relevant ODs are provided in Section 8 Operational Directives and Program Bulletins and include: Edit Protocol for Hospital Morbidity Data System Hospital Morbidity Information Hospital Morbidity Data Reporting Cycle Clinical Information Audit Program Hospital Activity Reporting Admission, Readmission, Discharge and Transfer Policy for WA Health Services (ARDT) HOSPITAL SYSTEMS REPORTING SCHEDULES PUBLIC HOSPITALS Public hospitals are required to submit 80% of their morbidity information for inclusion in the HMDS within two weeks of the discharge of the patient from hospital. The remaining 20% of morbidity information is to be submitted within four weeks of the discharge of the patient from hospital. Small and remote country hospitals, which are visited infrequently by coders, need to complete and submit their data within 8 weeks of the patient being discharged. See OD 0137/08: Hospital Morbidity Data Reporting Cycle. All records will be subjected to data quality screening once received by the HMDS. See OD 0136/08: Edit Protocol for Hospital Morbidity Data System. Hospitals have 10 working days, from the point of receipt of data quality reports or communication, to address and correct any data quality errors or issues. It is pivotal to hospital reimbursement and activity reporting that all data quality errors or issues are addressed in a timely manner. Any data quality errors or issues not addressed, will result in records remaining in error and not flowing through for inclusion in the HMDS. PRIVATE HOSPITALS In accordance with The Hospitals and Health Services Act 1927, private hospitals are required to provide inpatient statistics per the Annexure A of their license. From January 2014, this requirement included sites registering for MyFT secure data transfer application. Private hospitals are required to send their data to the IDC on a monthly basis. Hospitals have 10 working days, from the point of receipt of data quality reports or communication, to address and correct any data quality errors or issues pertaining to their monthly data submission.

17 See Appendix 10: Inpatient Statistics- HMDS. Guidelines for private hospitals are reviewed and updated as required and additional guideline documents may be issued to cover not only private hospitals but also kindred health care institutions. Enquiries regarding these guidelines may be addressed to the Director General of Health via: Manager Licensing and Accreditation Regulatory Unit Department of Health WA 189 Royal Street EAST PERTH WA 6004 VALIDATION OF SUBMITTED RECORDS A data quality edit is a business rule designed to validate the accuracy of a submitted record. Data elements are validated against expected values to identify any potential errors for correction. Inpatient information received from hospitals is used for: Key Performance Indicators (KPI) Activity Based Funding Clinical Indicators for the Office of Safety and Quality in Healthcare (OSQH) Health service monitoring, evaluation and planning Reporting to the Federal Government Research It is important that the quality and accuracy of the information received is of a high standard. Validation of cases submitted to HMDS from the hospitals is performed to maintain the quality of the information. Commented edits on unexpected values for a data item are returned to the hospitals for review. An edit is returned to the hospital as either a fatal or warning edit. TYPES OF DATA QUALITY EDITS There are two types of data quality edits in the HMDS: FATAL DATA QUALITY EDITS These edits are triggered when one or more 'critical' errors has been identified in the submitted episode of care. Generally, fatal edits occur when there is something erroneous, inconsistent or illogical within the episode of care that could potentially impact or impair the assignment of an AR- DRG. (However, this is not exclusive criteria for edits). Where a fatal edit is triggered the error values in question must be updated, otherwise the episode of care is considered invalid and will not flow through to the HMDS and consequently will not be reported or funded. Example: Edit 0426: Principal Diagnosis ICD codes needs to be at a lower level

18 This edit has been triggered because the value in the Principal Diagnosis field is considered incomplete and therefore invalid. Without a valid Principal Diagnosis code, AR-DRG assignment is not possible. It is possible that the first 3 characters are correct, however the 4th or 5th characters are missing. To correct, the coder should review the assigned code and add the necessary characters and resubmit the episode of care. WARNING DATA QUALITY EDITS These edits are triggered when one or more 'non-critical' errors have been identified in the submitted episode of care. Generally, warning edits occur when there is something erroneous, inconsistent, illogical or simply unusual within the episode of care that could compromise the data integrity of the episode of care and data reporting in general. Warning edits can be divided into two broad types: Non-critical: These edits indicate that there are erroneous or missing values within the episode of care and correction is required, but the reporting hospital needs to assess the episode of care more closely to identify which data element needs correction. Example: Edit 0761: Additional diagnosis Z51.5 and Care Type not 23 = Palliative Care This edit has been triggered because the Care Type field contains one of the following values: AND 21 - Acute Care 22 - Rehabilitation 24 - Psychogeriatric Care 25 - Maintenance Care 26 - Newborn 27 - Organ Procurement 28 - Boarder 29 - Geriatric Evaluation and Management 30 - Aged Care 31 - Flexible Care An Additional Diagnosis field contains the following ICD Code: Z51.5 Palliative Care This combination of Care Type and ICD Code is not consistent. One of the fields is incorrect and needs to be updated and the episode of care resubmitted. If the Care Type is incorrect, then the health unit should assign 23 - Palliative Care as the Care Type. If the ICD Code is incorrect, the code should be deleted. Warning: These edits indicate that there is an unusual value within the episode of care that may or may not be erroneous. Warning edits require review of the unusual information and health units should respond to these edits by verifying the unusual values or correcting values where they are identified as an actual error.

19 Example: Edit 0340: Aboriginal or Torres Strait Islander and country of birth is not Australia AND IMPORTANT This edit has been triggered because the Indigenous Status field contains one of the following values: 1 - Aboriginal not Torres Strait Islander 2 - Torres Strait Islander not Aboriginal 3 - Aboriginal and Torres Strait Islander The Country of Birth field does not contain one of the following values: Australia Australia (includes External Territories), nfd This combination of Indigenous Status and Country of Birth could be valid for the episode of care in question. However generally it is considered an unusual combination and therefore HMDS requires the health unit to verify that both fields are correct or update any error values and resubmit the episode of care. For public hospitals, please note: If the value of a data element for an episode of care in edit is not updated then the episode of care is not resent/reconfirmed. If the value of a data element is changed or corrected for an episode of care in edit, the episode of care should be resent/reconfirmed. MULTIPLE EDITS FOR SAME PATIENT It is possible that a single episode of care can trigger multiple edits, either related or unrelated to each other. Where this occurs the system user should address each edit in turn and make the necessary corrections and resend the episode of care to IDC. PROBLEMS WITH HMDS EDITS If you identify that a particular HMDS edit is incorrect or you believe it is the source of numerous queries, please contact the Data Quality Coordinator on (08) to discuss.

20 SECTION 4 Inpatient Data Collections RESPONSIBILITIES

21 INPATIENT DATA COLLECTION RESPONSIBILITIES This section provides information on the responsibilities of Inpatient Data Collections (IDC). The information provided in this section includes the maintenance, extraction and review of data submitted, and validation and training of coders. The staff of the IDC unit have the following responsibilities: SECURITY Maintain the security and confidentiality of the HMDS. CODING STANDARDS Ensure all coders in WA apply the Australian Coding Standards and WA Coding Standards. Represent WA Health on the International Classification of Diseases Technical Advisory Group for the Australian Consortium for Classification Development (ACCD). Chair the WA Clinical Coding Advisory Group. REVIEW OF DATA Review coded data, raise queries and provide feedback. Provide expert advice on the use of International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases and Health Related Problems, 10 th Revision, Australian Modification (ICD-10-AM) codes. Give decisions on code selection when required. Provide assistance and support for coding queries via and/or telephone. Manage global code tables, such as codes for establishments, postcodes and doctors specialties. Ensure that the edit checks are documented, designed, tested and implemented onto the HMDS database. Conduct quality assurance reviews of coded data on a regular basis. AUDITS Provide audit checks for hospitals, including strategies and recommendations for improvement. TRAINING Ensure coders are informed of all coding updates, conventions and rules. Inform all hospitals of new demographic data requirements. Promote liaison between the IDC and hospital staff. Provide continuing coding education. Maintain the Coding in W.A. website DATA RELEASE As stated in the Data Stewardship and Custodianship Policy, the Director General (DG) of WA Health is the delegated owner of all data and information collected, stored, used and disclosed within the various entities. The DG delegates a number of these responsibilities to senior officers to administer and/or manage.

22 The Manager, Inpatient Data Collections is the delegated Data Custodian for Hospital Morbidity Data and ensures accurate and accountable release of data. See OD0321/11: Data Stewardship and Custodianship Policy. DATA TIMELINESS Monitor the arrival of data files from the hospitals to ensure the agreed schedules are met. Process cases from the TOPAS, HCARe and webpas system within 48 hours of receipt. Process cases from other hospitals within one week of receipt. ASSIGNMENT OF DRG CODES Ensure that each case is grouped in all required versions of the DRG grouper. DATA EXTRACTION Provide effective explanation of morbidity data items and their use. Provide expert statistical advice to hospitals, medical officers, research workers and hospital administrators. Extract data on request in a timely manner.

23 SECTION 5 CODING STANDARDS

24 CODING STANDARDS In July 2013, the Australian Consortium for Classification Development (ACCD) acquired responsibility for managing and updating ICD-10-AM, Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS) in Australia under contract from the Independent Hospital Pricing Authority (IHPA). This section provides information on the responsibilities of coders and useful resources and contacts for coding in Western Australia. DEMOGRAPHIC STANDARDS The AIHW is progressively developing definitions to standardise the collection of data items throughout Australia to enable accurate analysis and comparison of information across all States and Territories. These definitions are regularly updated and published in the NHDD. Definitions used in this manual are consistent with those of the NHDD, available on METeOR. Some non-nhdd variables (for example client status) have been developed to reduce the number of items and questions to be asked of patients, but still allow extraction of the NHDD formats. CLINICAL CODING STANDARDS Clinical coders are responsible for translating the narrative descriptions of diagnoses and procedures into valid ICD and ACHI codes. The standards for translation and application of the ICD codes are defined in: ICD-10-AM WA Clinical Coding Advisory Group decisions and information: WA Coding Standards Coding Matters (previous publications of NCCC) Q & A National Casemix & Classification Centre: ACCD Classification Information Portal Coding Rules: The Australian Coding Standards are in place to ensure sound and consistent coding practice with ICD-10-AM and ACHI. The Coding Education Team (CET) at the Department of Health together with advice from the WA Clinical Coding Advisory Committee have developed a number of specific standards for WA coders. These standards take precedence over the ACS, and are located in Operational Circular 0154/08 and OD 0426/13: Western Australia Coding Standards. The CET is to be consulted when the interpretation of a coding standard is required or where the classification system has no code available for a given diagnosis or procedure. The ICD-10-AM, ACHI and ACS Eighth Edition, produced by the NCCC, are to be used to code all separations from 1st July 2013.

25 DATA ELEMENT DEFINITIONS

26 CONTENTS DATA ELEMENT DEFINITIONS... 4 HA22 FORM (HOSPITAL INPATIENT SUMMARY FORM)... 6 DERIVED DATA ELEMENTS... 6 NON-CLINICAL DATA ELEMENT DEFINITIONS... 7 ACCOMMODATION OCCUPIED... 8 ACCOUNT / ADMISSION NUMBER ADMISSION DATE ADMISSION STATUS ADMISSION TIME ADMISSION TIME ADMITTED FROM CARE TYPE CLIENT IDENTIFIER UNIT MEDICAL RECORD NUMBER CLIENT STATUS CLINICIAN ON ADMISSION CLINICIAN ON SEPARATION CONTRACTED / FUNDING ESTABLISHMENT COUNTRY / STATE OF BIRTH DATE OF BIRTH DAYS OF HOSPITAL IN THE HOME CARE DAYS OF PSYCHIATRIC CARE DAYS OF QUALIFIED NEWBORN CARE DISCHARGED TO DVA CARD COLOUR DVA FILE NUMBER EMPLOYMENT STATUS EPISODE OF CARE LINK FIELD

27 ESTABLISHMENT FIRST AND SECOND FORENAMES FUNDING SOURCE HOURS IN INTENSIVE CARE UNIT INDIGENOUS STATUS INFANT WEIGHT INSURANCE STATUS INTENDED LENGTH OF STAY INTERPRETER SERVICE LANGUAGE LEAVE DAYS (TOTAL) LEAVE PERIODS (NUMBER OF) MARITAL STATUS MEDICARE CARD NUMBER / MEDICARE PERSON NUMBER MENTAL HEALTH LEGAL STATUS MENTAL HEALTH LEGAL STATUS MODE OF SEPARATION MOTHER'S IDENTIFIER - UNIT MEDICAL RECORD NUMBER POSTCODE OF ADDRESS READMISSION STATUS RESIDENTIAL ADDRESS SEPARATION DATE SEPARATION TIME SEX SOURCE OF REFERRAL - LOCATION SOURCE OF REFERRAL - PROFESSIONAL SOURCE OF REFERRAL - TRANSPORT SPECIALTY OF CLINICIAN ON ADMISSION SPECIALTY OF CLINICIAN ON SEPARATION

28 STATE / TERRITORY SURNAME UNPLANNED RETURN TO THEATRE WARD / LOCATION CLINICAL DATA ELEMENT DEFINITIONS ACTIVITY ADDITIONAL DIAGNOSES ADDITIONAL PROCEDURE CLINICIAN PERFORMING PROCEDURE CO-DIAGNOSIS (CODE ALSO) CONDITION ONSET FLAG DATE OF PROCEDURE EXTERNAL CAUSE (OF INJURY) HOURS OF CONTINUOUS VENTILATORY SUPPORT MORPHOLOGY PLACE OF OCCURRENCE PRINCIPAL DIAGNOSIS PRINCIPAL PROCEDURE

29 DATA ELEMENT DEFINITIONS Section 6 provides specific information about every data element captured in the HMDS, including definitions, permitted values, applicable business rules and practical data collection information. Data is analysed across Australia, it is important that the same definitions are used for terms such as hospital, patient, admission and neonate. In most instances, the terms used in this manual are consistent with those used in the National Health Data Definition (NHDD), available on METeOR or those defined in the Operational Directive 0137/08: Hospital Morbidity Data Reporting Cycle of the PAQ Division of WA Health. METeOR is an AIHW website which contains national metadata standards for health, housing and community services statistics and information. Section 6 provides definitions for each data element reportable to HMDS and is divided into two sections: Non-Clinical Data Element Definitions Clinical Data Element Definitions The Non-Clinical Data Element Definitions incorporates all data elements that are deemed to be non-clinical and would generally be captured through normal administrative processes. For example, patient demographics, admission details and separation details. The Clinical Data Element Definitions incorporate all data elements that would normally be captured through morbidity coding processes. Clinical data elements directly correspond to the morbidity and treatment aspects that occur within an admission. For example, diagnoses, procedures, external cause and morphology details to name a few. Within both sections, the data element definitions are listed alphabetically. DATA DEFINITION FORMAT A standardised format has been applied to each data element. This format ensures that relevant information is presented consistently and efficiently to the reader. The following provides a definitional overview of the format: DATA ELEMENT TITLE Data element name: System specific names: Definition: Collection requirement: Specifies the official name of the data element in line with the HMDS. The term data element may also be referred to as field or data item. TOPAS: HCARe: webpas: Specifies the name of the equivalent data element as displayed in key hospital patient administration systems. Where the termed Derived is utilised, this means that the data element may not be displayed on user screens but is derived or auto-calculated by the system. Specifies the definition of the data element. Where possible, HMDS endeavours to align data element definitions with the National Health Data Dictionary (NHDD). Specifies whether the item must be provided for every case or only applies under special circumstances. The types of collection requirements for HMDS include: Mandatory must be collected 4

30 METeOR reference: Format: Maximum length: Permitted values: Conditional i.e. must be collected where certain conditions are met Not mandatory collection is optional Specifies the six-digit data element number of the equivalent data element in the NHDD. This field is hyperlinked for ease of reference. Specifies the format of the data element in relation to how it must be submitted to HMDS. Specifies the maximum length of the field in relation to how it must be submitted to HMDS. Specifies the permitted values to be entered. The term permitted values may also be known as data domain. Where there is a large number of Permitted Values, the reader is referred to the Appendices. GUIDE FOR USE Specifies general guidelines and business rules applicable to the collection of the data element as well as providing further clarification on key data collection issues. May also provide explanation on why the data element is collected and criteria for collection. VALUE DEFINITIONS 1 - Value Definition Title Provides a specific description of each value listed under the Permitted values. Not all data elements will have a list of permitted values. EXAMPLES Provides practical examples of how to capture the data element. Generally, the examples will cover a broad range of scenarios, incorporating pertinent guidelines or business rules under the Guide for Use. DATA QUALITY EDITS Edit Number Edit Message Edit Severity Specifies the error number as displayed on the HMDS error report Specifies the error message as displayed on HMDS error reports Specifies the HMDS severity and indicator or priority for correction 5

31 HA22 FORM (HOSPITAL INPATIENT SUMMARY FORM) Historically the HA22 form was used to manually submit data to IDC before the introduction of the electronic transfer of data. This form has been retained in the HMDS reference manual as it may be used as a temporary backup during system downtime. It is also a useful resource to indicate reportable data elements. Refer to Appendix 11 Hospital Inpatient Summary Form HA22 July DERIVED DATA ELEMENTS There are other data elements used by HMDS that are derived from the reportable data elements: Admission Age (in years): Calculated by year of [Admission Date] minus year of [Date of Birth]. If month/day of [Admission Date] is earlier than month/day of [Date of Birth], it is subtracted by 1. Event ID: Generated automatically for each case by HMDS for reference purposes. Length of Stay: Calculated by [Separation Date] minus [Admission Date] minus [Total Leave Days]. DRG: Generated by DRG Grouper software. The current version for 2013/14 is AR-DRG 7.0. If DRG values are supplied by the reporting hospitals, AR-DRG 6.0x values are also accepted. Major Diagnostic Category (MDC): Generated by DRG Grouper software. The current version for 2013/14 is AR-DRG 7.0. If MDC values are supplied by the reporting hospitals, AR-DRG 6.0x values are also accepted. 6

32 NON-CLINICAL DATA ELEMENT DEFINITIONS 7

33 ACCOMMODATION OCCUPIED Data element name: System specific names: Definition: Collection requirement: METeOR reference: Format: Accommodation Occupied TOPAS: HCARe: webpas: Actual Accommodation Pref Accom Room Type (CAT RT) The type of room occupied by the patient at discharge. Mandatory Not applicable Character Maximum length: 1 Permitted values: 1 - Single room 2 - Shared room VALUE DEFINITIONS 1 - Single room The patient occupies a room with a single bed and the room is not intended for occupancy by more than one person. This includes a mother rooming with her newborn. The room must be surrounded by walls with a door and may contain an en-suite. 2 - Shared room The patient occupies a room where the intended occupancy of the room is for more than one person. EXAMPLES Example 1: A patient occupies a bed in a four-bed ward. Accommodation Occupied 2 Example 2: A mother and her newborn baby occupy a single room intended for one person only. Accommodation Occupied 1 Example 3: A renal dialysis patient occupies a chair in a walled off area. Accommodation Occupied 1 8

34 Example 4: A same-day gastroenterology patient occupies a curtained off bed in an area with five other beds. Accommodation Occupied 2 DATA QUALITY EDITS Edit Number Edit Message Edit Severity 0644 Accommodation field not acceptable for separation date Warning 9

35 ACCOUNT / ADMISSION NUMBER Data element name: System specific names: Definition: Collection requirement: METeOR reference: Format: Account/Admission Number TOPAS: HCARe: webpas: Account Number Account Number Account Number The unique identifier of a hospital episode of care that may be used for billing. Mandatory Not applicable Character Maximum length: 12 Permitted values: Alpha/numeric combination up to 12 characters GUIDE FOR USE The Account/Admission Number can be alphanumeric or numeric up to a maximum of 12 characters. Boarders and neonates must have their own unique Account/Admission Numbers. EXAMPLES Example 1: A patient was admitted to a hospital and assigned as an Account Number. Account / Admission Number Example 2: A patient was admitted to hospital and assigned AB as the Account Number. Account / Admission Number A B DATA QUALITY EDITS Edit Number Edit Message Edit Severity 0067 Account number is not present Warning 0068 Account number is invalid Warning 10

36 ADMISSION DATE Data element name: System specific names: Definition: Collection requirement: Admission Date TOPAS: HCARe: webpas: Admission Date Admission Date Admission Date The date on which an admitted patient commences an episode of care that can be formal or statistical. Mandatory METeOR reference: Format: Date Maximum length: 8 Permitted values: DDMMYYYY GUIDE FOR USE Enter the full date of admission, including leading zeros where necessary. Formal Admission A formal admission is an administrative process that initiates a record of the patient's treatment and accommodation within a hospital. The Admission Date for a formal admission will be the date the hospital commenced treatment and accommodation of the patient. Statistical Admission A statistical admission is an administrative process that occurs within an episode of care and captures the commencement of a particular type of care (Care Type). The Admission Date for a statistical admission will be the date the patient commenced a particular Care Type. EXAMPLES Example 1: A patient was admitted on the 8 th January Admission Date

37 Example 2: A patient was statistically admitted (e.g. change in care type from acute care to rehabilitation) on the 1 st February Admission Date DATA QUALITY EDITS Edit Number Edit Message Edit Severity 0147 Invalid admission date for establishment Warning 0232 Admission date is not present Fatal 0234 Admission date is after the separation date Fatal 0236 Separation date is before the admission date Fatal 0250 Country of birth must be WA if admission date = birthdate Warning 0347 Date of procedure is outside the admission and separation dates Warning 0475 The date of birth must equal the admission date Warning 0755 LOS > 365 days for acute patient Warning 12

38 ADMISSION STATUS Data element name: System specific names: Definition: Collection requirement: Admission Status TOPAS: HCARe: webpas: Admission Status Admission Status Admission Status (CAT P) The urgency of the patient's admission to hospital and whether the admission occurred on an emergency or elective basis. Mandatory METeOR reference: Format: Character Maximum length: 1 Permitted values: 3 - Elective waitlist 4 - Elective not waitlist 6 - Emergency Emergency Department admission 7 - Emergency Direct admission GUIDE FOR USE All admissions must have an urgency status assigned to indicate if the admission occurred on an emergency basis or elective basis. Definition of "Emergency" An emergency admission is an admission of a patient for care or treatment which, in the opinion of the treating clinician, is necessary and admission for which should occur within 24 hours. Emergency care includes patients suffering from an acute illness or injury that requires urgent assessment and treatment. These patients are usually admitted via the Emergency Department or may be a direct admission to an Intensive Care Unit, Burns Unit or other specialty area. An admission, from a private medical practice directly to hospital, which has not been placed on a formal booking list or waitlist, is an emergency admission. Patients admitted as emergency admissions cannot be considered as being admitted from the waitlist. Some obstetric cases may also qualify as emergency admissions. For example, patients who deliver at least one month prior to term or are admitted before the expected date of delivery for treatment of an acute illness or injury should be regarded as emergency admissions. VALUE DEFINITIONS 3 - Elective - waitlist The category should be used for admission of a patient for care which, in the opinion of the treating clinician, is necessary and admission can be delayed for at least twenty-four hours. 13

39 The Wait List is the centralised list of patients requiring care that is managed by WA Health. Cases may or may not have a scheduled admission date assigned. Patients on the waiting list are assigned a clinical urgency status to prioritise the urgency with which they require elective hospital care. Elective Waitlist patients may include cases under investigation for a non-urgent illness, or planned non-urgent procedures (e.g. an admission for sterilisation or cholecystectomy procedures). 4 - Elective - not waitlist An elective admission is an admission of a patient for care or treatment which, in the opinion of the treating clinician, is necessary and an admission that can be delayed for at least 24 hours. These patients are not entered on the centralised waitlist but may be entered on booking lists that have a scheduled date of admission assigned. Elective not Waitlist patients that may include non-urgent obstetric cases, repeat admissions for renal dialysis, chemotherapy, check cystoscopy and follow-up endoscopy. Newborn babies in the birth episode or babies born before arrival at hospital are always elective not waitlist admissions. 6 - Emergency - Emergency Department admission This category applies to patients admitted via the hospital s own Emergency Department. 7 - Emergency - Direct admission This category applies to patients directly admitted to hospital without admission via the hospital s own Emergency Department. This includes patients admitted via the Emergency Department of another establishment. EXAMPLES Example 1: A patient admitted for treatment of abdominal pain through the hospital s Emergency Department and deemed to require treatment within 24 hours. Admission Status 6 Emergency Emergency Department admission Example 2: A patient admitted with a term pregnancy for caesarean section. Admission Status should be Elective not waitlist. Admission Status 4 Elective not waitlist Example 3: A patient who is admitted for ligation of varicose veins and this procedure was scheduled on the hospital waiting list. Admission Status 3 Elective - waitlist Example 4: A critically ill patient admitted directly to the intensive care unit at RPH transferred from Armadale-Kelmscott Hospital. Admission Status 7 Emergency Direct admission 14

40 DATA QUALITY EDITS Edit Number Edit Message Edit Severity 0153 Admission status is not present Fatal 0154 Admission status value is not a valid code Fatal 15

41 ADMISSION TIME Data element name: Admission Time System specific names: TOPAS: HCARe: webpas: Admission Time Admission Time Admission Time Definition: Collection requirement: The time at which an admitted patient commences an episode of care that can be formal or statistical. It is required to identify the time of commencement of the episode or hospital stay. Mandatory METeOR reference: Format: Time Maximum length: 4 Permitted values: HHMM GUIDE FOR USE The time of admission or birth should be completed in the appropriate boxes. This should be written using the 24-hour clock. EXAMPLES Example 1: A patient was admitted at midnight. Admission Time Example 2: A patient was statistically admitted (e.g. change in care type from acute care to rehabilitation) at 5.25pm. Admission Time DATA QUALITY EDITS Edit Number Edit Message Edit Severity 0471 Admission time value is not present Fatal 16

42 ADMITTED FROM Data element name: System specific names: Definition: Collection requirement: METeOR reference: Format: Admitted From TOPAS: HCARe: webpas: Transferring Medical Facility Establishment/Organisation Unit Hospital The establishment or facility from which the patient is admitted from. Mandatory Not applicable Number Maximum length: 4 Permitted values: See Appendices 1A and 1B: Admitted From/Discharged To Establishment List GUIDE FOR USE The reference table for this data element consists of a combination of formal reporting establishments (such as acute care hospitals) and organisations or facilities that may or may not be a health service. This data element is captured on admission and identifies the specific Establishment or Facility from which the patient has come from. All newborn babies, or babies born before arrival at hospital, must be admitted from Home. New establishments that are residential aged care or other health care accommodation with no current establishment number should be assigned Unlisted Residential Aged Care Service or Unlisted Other Health Care Accommodation. These are not valid establishment codes but are used to allow a patient to be admitted or discharged until HMDS has created a valid establishment number. Edits will be generated when codes 4098 and 4099 are used. These establishment numbers are temporary. The case will need to be resent/reconfirmed once the new establishment number has been added to the case. It is the hospital s responsibility to advise IDC that creation of a new establishment is required. For contracted services, the hospital funding the contracted service must assign 0999 in this field. EXAMPLES Example 1: Patient admitted following a transfer from Beverley Hospital. Admitted From