HEALTH INFORMATION STANDARDS COMMITTEE FOR ALBERTA MENTAL HEALTH REPORTING REQUIREMENTS INPATIENT INTERVAL REPORTING DATA SET

Transcription

1 Health Information Data Standard HEALTH INFORMATION STANDARDS COMMITTEE FOR ALBERTA MENTAL HEALTH REPORTING REQUIREMENTS INPATIENT INTERVAL REPORTING DATA SET Status: Accepted in Draft Amendment Version 0.1 Status Date: January 20, 2009

2 Revision History Version Revision Date Summary of Changes 0.2 February 11, 2010 Application as built data elements 2010 Government of Alberta 2 of 103

3 Table of Contents Revision History...2 Table of Contents...3 EXECUTIVE SUMMARY...5 INTRODUCTION...6 BACKGROUND...6 BUSINESS CASE FOR THE HEALTH SYSTEM...6 IMPACT ON PRIVACY, CONFIDENTIALITY AND SECURITY...7 RELATIONSHIP TO EXISTING STANDARDS AND/OR LEGISLATION...7 SUMMARY OF CONSENSUS TO DATE...8 RESULTS OF LITERATURE REVIEW...8 Conceptual Data Model...9 Data Standards Stakeholder...12 Unique Lifetime Identifier (ULI)...13 Aboriginal Status...14 Stakeholder Health Care Number...15 Health Care Number (HCN)...16 Province/Territory Issuing Health Care Number...17 Stakeholder Gender...18 Gender...19 Stakeholder Date of Birth...20 Birth Date...21 Birth Date...22 Service Episode...23 Episode Start...24 Chart Number...25 Admission Date...26 Admission via Ambulance...27 Accompanied By at Admission...28 Patient Referred By...29 Date of Referral...31 Address...32 Province of Patient's Residence...33 Postal Code of Patient's Current Residence...34 Postal Code of Patient's Current Residence Known Flag...35 Homeless Flag...36 Other Country Flag...37 Service Episode Program...38 Service Program Start Date...39 Mental Health Program...40 Mental Health Program...41 Inpatient Status...42 Psychiatric Status...43 Public Guardian Code...45 Responsibility for Payment...46 Forensic Legal Status...47 Health Diagnosis...48 Diagnosis...49 DSM-IV-TR Description Code...50 DSM-IV-TR AXIS Code...51 ICD-10-CA Code...53 ICD-10-CA Prefix Code...54 DSM-IV-TR GAF Score...55 Service Episode Responsible Provider Government of Alberta 3 of 103

4 Most Responsible Provider ID...58 Most Responsible Provider Expertise...59 Stakeholder Service Event...60 Service Event Identifier...61 Service Event Start Date...62 Group Service Event Flag...63 Number of Participants in Group...64 Service Event Duration...65 Intervention Code...66 Intervention Attribute Status...67 Intervention Attribute Mode of Delivery...68 Intervention Attribute Extent...69 Service Provider...71 Service Provider ID...72 Service Provider Role...73 Service Provider Role...74 Inpatient Discharge Waitlist...75 Date Placed on Discharge Waitlist...76 Reason Placed on Discharge Waitlist...77 Date Taken off Discharge Waitlist...79 Episode Close...80 Discharge Date...81 Discharge Disposition...82 of Residence Discharged To...84 Facility Number of Institution Transferred To...85 Facility...86 Delivery Site/Institution Number...87 Permissible Values...88 DSM-IV-TR Description Code Table Government of Alberta 4 of 103

5 EXECUTIVE SUMMARY With the shift of responsibility for mental health services from the Alberta Mental Health Board (AMHB) to the Regional Health Authorities (RHAs) in 2004, the Mental Health Reporting Initiative (Initiative) was undertaken to ensure the continuity of available information for (AHW) and the AMHB to perform their business functions. It is anticipated that the information resulting from the Initiative will also meet most RHAs mental health information requirements. In order to meet the identified information needs new reporting requirements have been developed for collection at the five provincial mental health facilities. The reported data will be used to provide information for surveillance on mental health disorders and related services, measure mental health services develop a funding model and costing methodology for mental health services and assess utilization and quality improvement activities. The collected data will be submitted to AHW through a new application which will validate the received data, allow authorized users to review the file-processing results and provide pre-defined reports on aggregate provincial data. The improved mental health data will be available in a repository environment Government of Alberta 5 of 103

6 INTRODUCTION The Alberta Mental Health Board (AMHB) was formed in 1994 with the mandate to deliver mental health services across the province. In May of 2004, the AMHB unveiled the Provincial Mental Health Plan. Under this plan the roles and responsibilities of the various organizations involved in mental health were redefined. (AHW) was given overall responsibility for maintaining the provincial policy framework for mental health by entering into performance agreements with health authorities, monitoring results, and determining policy and funding requirements. These changes transferred the primary responsibility of collecting data and providing information related to mental health services from the AMHB to AHW. To facilitate this transfer, a review of the existing systems and processes for collecting and submitting data was performed. It revealed some gaps in terms of the quality of the data collected in its accuracy, completeness and timeliness. Currently there is no well defined standard for the data to be collected and submitted and this negatively impacts the quality of the data and information available. Some service providers do not report any data on mental health services provided and some facilities do not report data on all of the mental health services they provide. Data related to inpatient services provided at mental health facilities and acute care hospitals is only provided in summary form and at time of discharge. As well, the existing processes for data submission and correction are inefficient, arduous, error prone and not well documented or universally understood. Due to a lack of standards and a uniform automated mechanism for submitting data, a significant amount of work is required to request, receive and correct the data. The gaps of the data being collected and the issues with the related existing processes represent an opportunity for the Initiative to clarify reporting requirements and improve the submission process by creating new applications and modifying existing systems. This, in turn, will improve the information available for all stakeholders to assist them in achieving their mandates. To support the changes introduced by the Provincial Mental Health Plan and capitalize on the opportunities it presented, AHW commenced the Initiative which comprises several projects and phases. The first Project defined under this Initiative consists of two phases: A Requirements Analysis and Architecture phase (Phase 1); and a Detailed Design phase (Phase 2). Phase 1 completed in March Phase 2 completed in December Phase 3, the Construction and Implementation phase, will be completed by March 2009 with data collection commencing with the 2009/2010 fiscal year. The Inpatient Interval Reporting Requirements will be collected by the five provincial mental health facilities including Alberta Hospital Edmonton, Claresholm Centre for Mental Health and Addictions, Raymond Care Centre, Southern Alberta Forensic Psychiatric Centre and The Centennial Centre for Mental Health and Brain Injury. The facilities will report the data to AHW on a quarterly basis resulting in timely data being available on service recipients who remain inpatients for extended periods. The new reporting requirements compliment the current reporting required upon patient discharge for submission to the Canadian Institute for Health Information (CIHI) and do not replace it. BACKGROUND BUSINESS CASE FOR THE HEALTH SYSTEM Mental Health Inpatient Interval reporting will provide AHW with the information necessary to meet its legislative and program management requirements. As well the new reporting will aid AHW in achieving the Business Plan Strategy 3.2 which states Support the community-based implementation of the Provincial Mental Health Plan and new patient activity reporting requirements in partnership with the Alberta Mental Health Board, regional health authorities and other stakeholders. The AMHB has been assigned an important advisory role for mental health in the province and is responsible for specific provincial leadership collaboration, coordination and support activities in areas such as Aboriginal mental health, forensic services, mental health research planning and coordination, performance standards and measures, and province-wide prevention and promotion initiatives. These roles and responsibilities can only be successfully achieved through the availability of quality mental health data. The RHAs are the primary organizations responsible for delivering mental health services. They are solely accountable to the Minister, through their Boards, for fulfilling their respective roles and responsibilities as 2010 Government of Alberta 6 of 103

7 detailed in legislation and in their performance agreements. Each RHA needs data to develop appropriate performance agreements, as well as information to measure their performance and to compare their mental health service delivery to provincial standards. Mental health data needs to be collected and available for analysis at a provincial level to support the needs of the stakeholders including AHW, AMHB, the RHAs and individual Albertans in need of mental health services. The benefits to the stakeholders as a result of this Initiative include: AHW will receive the necessary mental health information to support the Ministry mandate of health surveillance, performance measures, funding and assessment of mental health services; The AMHB will receive the information it requires for use in developing and monitoring provincial mental health programs and policy, conducting mental health needs assessment, and assessing the overall performance of the mental health system; RHAs will receive appropriate funding for the mental health care services required in their regions as well as the data required to measure their performance and compare it with provincial standards; External agencies and research organizations, will receive the information they require on mental health services; All stakeholders will receive more accurate, complete and timely information; and Albertans will have necessary mental health services available to them in a cost effective and efficient manner. In addition to the opportunities at hand, there are risks associated with delaying or not proceeding with the Initiative. Until standards for the data required are finalized and communicated to all service providers and a mechanism for the submission of this data is available, some service providers will continue to not supply data or not supply all of the required data. This represents a risk in terms of a loss of data continuity that translates into negative impacts for all stakeholders requiring the data to meet their information needs. Furthermore, many of the RHAs are currently involved in initiatives to replace their existing systems used to collect and submit data on services provided. Delays in the Initiative could jeopardize the ability of these new systems to satisfy mental health reporting requirements. IMPACT ON PRIVACY, CONFIDENTIALITY AND SECURITY is initiating a Privacy Impact Assessment (PIA) in parallel with this HISCA submission regarding their requirement to receive detailed mental health data in accordance with this proposed standard. The PIA process has been initiated and will progress to completion during Phase 2 of the Project. RELATIONSHIP TO EXISTING STANDARDS AND/OR LEGISLATION The Inpatient Interval Reporting Requirements were aligned with standards already approved or accepted in draft format by HISCA. These standards include: Stakeholder Demographic Data Standard v2.2 Stakeholder Client Data Standard v1.0 Stakeholder Provider Data Standard (upcoming NEW version) Where no HISCA standards exist, similar data elements were aligned with the Canadian Institute for Health Information s (CIHI) Discharge Abstract Database (DAD) abstracting manual Government of Alberta 7 of 103

8 SUMMARY OF CONSENSUS TO DATE The requirements for Inpatient Interval Reporting were vetted through three primary entities to establish consensus including the AMHB, RHAs and AHW. The vetting process included a review of the data elements collected historically and assessed these elements for their current accuracy and utility. Additional data elements required to meet new information needs were also introduced and reviewed by representatives of the three organizations. AHW HISCA team members were consulted on standards application throughout the first two Project phases. The Inpatient Interval Reporting Requirements were accepted for implementation by the Project Working Group and Project Steering Committee which included representatives from the AMHB, RHAs and AHW. RESULTS OF LITERATURE REVIEW Early in the development of the Inpatient Interval reporting requirements, a comprehensive review of the Ontario Mental Health Reporting System (OMHRS) Minimum Data Set User s Manual (version 2005) was completed. A comparison between that data set and the data historically collected for the AMHB was completed. The analyses showed that the data required for OMHRS was significantly more detailed, particularly in the area of service recipient assessment. On providing the comparison results to the Project Steering Committee, the decision was made not to proceed with further investigation of OMHRS for Alberta implementation at this time due to the resource intensiveness of data collection as well as the infancy of the reporting system with no proven value. Additional literature review was not completed Government of Alberta 8 of 103

9 Conceptual Data Model Event Linkage links/ Is linked by Event delivers/ Is delivered as Governance Program Mental Health Program offers/ is offered in Service offered by/ offers Delivery Site Facility Service Event Mental Health Event Admission Discharge Stakeholder Service Event initiates/ initiated by closes/ terminated by happens within/ includes Service Episode happens within/ Is location of occurs at/ Is location of Communication Event Resource Event Referral Discharge Waitlist participates in/ has as a participant participates in/ has as a participant Stakeholder in a Role Provider Health Service Professional Worker Recipient has/ Is for Communication Access Address possesses/ is possessed by Provider Expertise establishes/ is established by establishes/ is established by is in/ is a Stakeholder Person Group Organization has a characteristic of/ Is a characteristic of Health Status references/ is referenced by Explanation of Symbols Entity defines a collection of stored data Relationship describes how two Entities relate to one another Entity maintained outside of Mental Health Reporting Mental Health Reporting AHEAD-aligned Conceptual Data Model Health Diagnosis 2010 Government of Alberta 9 of 103

10 Logical Data Model Address Province of Patient's Residence Postal Code of Patient's Current Residence Postal Code of Patient's Current Residence Known Flag Homeless Flag Other Country Flag admits from Episode Start Chart Number Admission Date Admission via Ambulance Accompanied By at Admission Patient Referred By Date of Referral Episode Close Discharge Date Discharge Disposition of Residence Discharged To Facility Number of Institution Transferred To Stakeholder ULI (Unique Lifetime Identifier) Aboriginal Status has Stakeholder Health Care Number Health Care Number Province Territory Issuing Health Care Number transfers to identifies Stakeholder Gender Gender concludes with begins Facility Delivery Site/Institution Number Stakeholder Date Of Birth identifies Birth Date Birth Date Service Episode experiences is located at Explanation of Symbols Entity Entity defines a collection of stored data Abstract Entity Represents the period of time between the Episode Start and any Episode Close Relationship describes how two Entities relate to one another Attributes in Bold have HISCA equivalent Service Episode Responsible Provider Most Reponsible Provider ID Most Responsible Provider Expertise is responsible for records establishes admitted to Inpatient Status Psychiatric Status Public Guardian Code Responsibility for Payment Forensic Legal Status Health Diagnosis Mental Health Program Mental Health Program is delivered by Service Episode Program Service Program Start Date requires is included in Diagnosis DSM-IV-TR AXIS Code DSM-IV-TR Description Code ICD-10-CA Code ICD-10-CA Prefix Code DSM-IV-TR GAF Score Service Provider Service Provider ID performs Service Provider Role Service Provider Role participates in performed on Stakeholder Service Event Service Event Identifier Service Event Start Date Group Service Event Flag Number of Participants in Group Service Event Duration Intervention Code Intervention Attribute Status Intervention Attribute Mode of Delivery Intervention Attribute Extent Inpatient Discharge Waitlist Date Placed on Discharge Waitlist Reason Placed on Discharge Waitlist Date Taken off Discharge Waitlist 2010 Government of Alberta 10 of 103

11 Data Standards Parent Component Name Stakeholder Service Episode Cardinality Business Rule/Coding Guideline 2010 Government of Alberta 11 of 103

12 Parent Stakeholder Component Name Cardinality For MHR, a person who receives mental health services. A Stakeholder is the target of one or more Mental Health Inpatient Service Episodes and receives the performance of one or more Mental Health Service Events while admitted into a Facility and registered in a Mental Health Program. Business Rule/Coding Guideline 2010 Government of Alberta 12 of 103

13 Data Element Name Unique Lifetime Identifier (ULI) Stakeholder Stakeholder Demographic Version 2.2 ULI is a distinct and permanent number assigned to all patients who receive health services in Alberta. ULIs are assigned to all Alberta residents, residents of other provinces/territories and other countries. Numeric Information Exchange Length 9 Mask NNNNNNNNN Mandatory Cardinality 1:1 Business Rule / Coding Guideline All people encountering the health care system in Alberta should be assigned a ULI. If a ULI does not exist at the time of admission, one can be assigned by authorized users of the Alberta Health and Wellness Person Directory (PD). The health care insurance number of the patient's home province or territory should be collected and recorded in PD to help identify and support medical and hospital reciprocal billing. The eligibility of a patient claiming coverage under the Alberta Health Care Insurance Plan (AHCIP) can be verified using PD. Implementation Consideration Permissible Data Element Value HISCA Alias Valid Alberta ULI - Numeric ULI 2010 Government of Alberta 13 of 103

14 Data Element Name Aboriginal Status Stakeholder Aboriginal Status identifies the indigenous background of the patient. Character Information Exchange Length 2 Mask AA Optional Cardinality 0:1 Business Rule / Coding Guideline This data element is optionally reported if the Aboriginal Status of the patient is known. Implementation Consideration Permissible Data Element Value HISCA Alias NS - First Nations - Non Status ST - First Nations - Status IT - Inuit MT - Métis OT - Other NA - Not Applicable Aboriginal Code 2010 Government of Alberta 14 of 103

15 Parent Component Name Stakeholder Health Care Number Stakeholder Information Health Care Number (HCN) Province/Territory Issuing Health Care Number Cardinality The value of the Inpatient Identifier (Health Care Number). Business Rule/Coding Guideline 2010 Government of Alberta 15 of 103

16 Data Element Name Health Care Number (HCN) Stakeholder Health Care Number Stakeholder Demographic Version 2.2 HCN is the patient's medical (insurance) number assigned by the provincial/territorial government of the patient's home residence. For Alberta residents, the Unique Lifetime Identifier (ULI) and the HCN are the same number. When the resident is insured under the Alberta Health Care Insurance Plan (AHCIP) the Alberta ULI is also considered the HCN. Character Information Exchange Length 12 Mask AAAAAAAAAAAA Mandatory Cardinality 1:1 Business Rule / Coding Guideline For Alberta, valid Health Care Numbers (HCNs) are ULIs that have been assigned to people upon registration in the Alberta Health and Wellness Stakeholder Registry. A complete set of HCNs for other provinces/territories is not available. The Alberta Person Directory may be a source of HCNs for out-of-province patients receiving health services in Alberta. Implementation Consideration Permissible Data Element Value HISCA Alias Up to twelve (12) characters; patient's Health Care Number as assigned by the province/territory of residence. 0 - Insured resident of Alberta, but Health Care Number not available 1 - Not Applicable. Includes: Out of Province Resident with unavailable Health Care Number. Out of country, federal government coverage (e.g. RCMP, penitentiary inmate, veteran) or no health insurance coverage from province of residence. PHN (Provincial Health Number) 2010 Government of Alberta 16 of 103

17 Data Element Name Province/Territory Issuing Health Care Number Stakeholder Health Care Number Province/Territory Issuing Health Care Number is a code that identifies the jurisdiction that issued/assigned the Provincial Health Care Number to the patient. Character Information Exchange Length 2 Mask AA Conditional Cardinality 0:1 Business Rule / Coding Guideline Assign the code that identifies the province or territory responsible for issuing the Health Care Number (HCN). This field is left blank if the HCN is reported as "1" in instances where the patient is out of province with an unavailable HCN. The field is also left blank when the patient is from another country, there is federal government coverage (e.g. RCMP, penitentiary, inmate, veteran) or no health insurance coverage from the province of residence. Implementation Consideration Permissible Data Element Value HISCA Alias AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland & Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Territory ID Assigning Authority 2010 Government of Alberta 17 of 103

18 Parent Component Name Stakeholder Gender Stakeholder Gender Cardinality A coded value that describes the sex of the patient. Business Rule/Coding Guideline 2010 Government of Alberta 18 of 103

19 Data Element Name Gender Stakeholder Gender Client Registry - Enterprise Management Person Identifier Gender is a coded value that describes the sex of the patient. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline The value of "Unknown" is used to indicate that the gender is unknown because the patient was not asked or did not provide the information. Implementation Consideration Permissible Data Element Value HISCA Alias F Female M Male U Unknown O - Other (transsexual, hermaphrodite) Administrative Gender 2010 Government of Alberta 19 of 103

20 Parent Component Name Stakeholder Date of Birth Stakeholder Birth Date Birth Date Cardinality At a point in time the whole or partial data of birth declared by a Mental Health Inpatient Business Rule/Coding Guideline 2010 Government of Alberta 20 of 103

21 Data Element Name Birth Date Stakeholder Date of Birth Client Registry - Enterprise Management Person Identifier Birth Date is the portion of the date of birth that is known and reported. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline Report the code that identifies the components of the birth date (i.e. year/month/day) that are known at the conclusion of the current reporting interval. If the complete birth date is known, report "5" - YYYYMMDD - Full Date of Birth Provided. Partial birth dates are allowed. If Birth Date reported is "3" - YYYY - Year only, "4" - YYYYMM - Year and Month only, or "5" - YYYYMMDD - Full Date of Birth Provided, then a corresponding birth date value must be reported. If documentation from a recognized jurisdictional authority verifies that an individual has no known birth date, "Birth Date" can be blank with a 1" - None reported in the Birth Date. If the "Birth Date" is not collected because it was not asked for or provided, report 2" - Not Collected in the Birth Date and leave "Birth Date" blank. Implementation Consideration Permissible Data Element Value HISCA Alias 1 - None - individual without a recorded date of birth and supported by documentation from a recognized jurisdictional authority 2 - Not Collected - Birth Date not provided 3 - YYYY - Year only 4 - YYYYMM - Year and Month Only 5 - YYYYMMDD - Full Date of Birth Provided Birth Date Component Part 2010 Government of Alberta 21 of 103

22 Data Element Name Birth Date Stakeholder Date of Birth Client Registry - Enterprise Management Person Identifier The Birth Date identifies the year, month and day when the patient was born. Date Information Exchange Length 8 Mask YYYY YYYYMM YYYYMMDD Conditional Cardinality 0:1 Business Rule / Coding Guideline Report the birth date information that is known. Partial birth dates may be reported. The birth date information that is reported must match the code reported for the data element "Birth Date." This data element is left blank if no part of the Birth Date is known. Implementation Consideration Permissible Data Element Value HISCA Alias YYYY YYYYMM YYYYMMDD Blank Birth Date Value 2010 Government of Alberta 22 of 103

23 Parent Component Name Service Episode Episode Start Service Episode Program Inpatient Status Health Diagnosis Service Episode Responsible Provider Stakeholder Service Event Inpatient Discharge Waitlist Episode Close Cardinality The delivery of a Mental Health Service to a single Stakeholder who is enrolled as a Mental Health Inpatient at a Facility Business Rule/Coding Guideline 2010 Government of Alberta 23 of 103

24 Parent Component Name Episode Start Service Episode Chart Number Admission Date Admission via Ambulance Accompanied By at Admission Patient Referred By Date of Referral Address Cardinality The event that initiates the enrolment of Stakeholder at a Facility under a Mental Health Program as Mental Health Inpatient and so begins an Inpatient Service Episode. A possible long running event initiated by a Mental Health Inpatient Admission that registers a Stakeholder as an Inpatient at a Facility to receive services under a Mental Health Program Business Rule/Coding Guideline 2010 Government of Alberta 24 of 103

25 Data Element Name Chart Number Episode Start Chart Number refers to the patient record number assigned by the reporting facility. Character Information Exchange Length 12 Mask AAAAAAAAAAAA Optional Cardinality 0:1 Business Rule / Coding Guideline Report the Chart Number assigned to the patient record by the facility. Implementation Consideration Permissible Data Element Value HISCA Alias Number assigned by the service provider organization. The number may be a combination of alpha and numeric characters. Patient Internal File Identifier 2010 Government of Alberta 25 of 103

26 Data Element Name Admission Date Episode Start Admission Date is the calendar date that the patient was officially registered as an inpatient at the facility. Date Information Exchange Length 8 Mask YYYYMMDD Mandatory Cardinality 1:1 Business Rule / Coding Guideline The Admission Date must be a valid date and be reported in the YYYYMMDD format. Implementation Consideration Permissible Data Element Value HISCA Alias Valid Date (YYYYMMDD) Service Episode Start Date 2010 Government of Alberta 26 of 103

27 Data Element Name Admission via Ambulance Episode Start Admission via Ambulance identifies whether or not the patient arrives at the facility in an ambulance. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline Report the applicable type of ambulance. Report "N" - No Ambulance if the patient did not arrive at the facility in an ambulance. Patient record documentation must support reporting that the patient arrived by ambulance. Implementation Consideration Permissible Data Element Value HISCA Alias A - Air Ambulance G - Ground Ambulance C - Combination of Ground and Air N - No Ambulance Transportation Mode Code 2010 Government of Alberta 27 of 103

28 Data Element Name Accompanied By at Admission Episode Start Accompanied By at Admission identifies who the patient was accompanied by at the time of admission. Character Information Exchange Length 2 Mask AA Conditional Cardinality 0:1 Business Rule / Coding Guideline This data element must be reported if the patient did not arrive at the facility by ambulance. Implementation Consideration Permissible Data Element Value 01 - Central Assessment & Placement Services 02 - Community Nurse 03 - Crisis Team 04 - Friend(s) 05 - Military Police 06 - Police 07 - Relative 08 - Self 09 - Social Worker 10 - Therapist 94 - Other 99 - Unknown HISCA Alias 2010 Government of Alberta 28 of 103

29 Data Element Name Patient Referred By Episode Start Patient Referred By identifies the type of person or agency that referred the patient for treatment at the facility. Character Information Exchange Length 2 Mask AA Mandatory Cardinality 1:1 Business Rule / Coding Guideline In the event that multiple referral sources apply, report the value that describes the most current referral source. The exception to this is in the situation when the patient is admitted to a mental health facility from an acute care facility after being brought in by the police under a Form 8. In this situation report 12 Legal System. Implementation Consideration Permissible Data Element Value 00 - No referral documented 01 - Acute care facility including tertiary care and community health care facilities 02 - Continuing care facility including extended care and nursing home facilities 03 - Other health care service providers (funded by regional resources) 04 - Home Care 05 - Services funded by non-regional resources (e.g. federal government, WCB) 06 - Physician (only used when referred by a physician in private practice) 07 - Public Health 08 - Other individual/ agency (e.g. private organizations) 09 - Significant other (Individuals who are acting on behalf, or in the interest of the patient such as a parent, spouse/partner, child, legal guardian or substitute decision maker. Excluded in this definition are 2010 Government of Alberta 29 of 103

30 nurses, Aides, ministers, teachers or health service personnel.) 10 - Educational Institution 11 Self (Patient approached the mental health facility without any encouragement from another person/agency) 12 - Legal System (e.g. corrections, court, police) 13 - Government funded alcohol and drug treatment agency (e.g. AADAC) 14 - Crisis Services 15 - Community mental health 16 - Psychiatric Facility (Alberta Hospital Edmonton, The Centennial Centre for Mental Health and Brain Injury, Claresholm Centre for Mental Health and Addictions, Southern Alberta Forensic Psychiatric Centre, or Raymond Psychiatric Centre) 17 - Child welfare services (e.g. Child and Family Services) 99 - Unknown HISCA Alias Referral Source Code 2010 Government of Alberta 30 of 103

31 Data Element Name Date of Referral Episode Start Date of Referral is the calendar date that the service provider is notified that the patient is being referred for services. Date Information Exchange Length 8 Mask YYYYMMDD Optional (Changed from Conditional to Optional to facilitate reporting data element for 2009/2010) Cardinality 0:1 Business Rule / Coding Guideline If the data element "Patient Referred By" is reported as a value other than "00" - No referral documented or "99" - Unknown, the Date of Referral must also be reported. If a referral occurs before the patient is admitted, report the date the referral was made. NOTE: For 2009/2010 this conditional reporting rule will not be enforced. Reporting of this data element is optional. Implementation Consideration Permissible Data Element Value HISCA Alias Valid Date (YYYYMMDD) Referral Source Date 2010 Government of Alberta 31 of 103

32 Parent Component Name Address Episode Start Province of Patient's Residence Postal Code of Patient's Current Residence Known Flag Homeless Flag Other Country Flag Cardinality At the time of Mental Health Inpatient Admission the residence information identified for a Stakeholder. Business Rule/Coding Guideline 2010 Government of Alberta 32 of 103

33 Data Element Name Province of Patient's Residence Address Stakeholder Demographic Version 2.2 Province of Patient's Residence indicates the jurisdiction that the patient normally resides in. Character Information Exchange Length 2 Mask AA Conditional Cardinality 0:1 Business Rule / Coding Guideline Report the code that indicates the province/territory that the patient normally resides in. This field is left blank if the patient usually resides outside of Canada. In these instances the data element "Other Country Flag" would be reported as "Yes." If the province of the patient s residence is unknown or unavailable, report AB. Implementation Consideration Permissible Data Element Value HISCA Alias AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland & Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Territory Province Code 2010 Government of Alberta 33 of 103

34 Data Element Name Postal Code of Patient's Current Residence Address Stakeholder Demographic Version 2.2 Postal Code of Patient's Current Residence is a six character letter/number combination assigned by Canada Post that identifies the patient's place of residence prior to admission. Character Information Exchange Length 6 Mask ANANAN Conditional Cardinality 0:1 Business Rule / Coding Guideline The format of the postal code is ANANAN, where "A" is an allowable character (D, F, I, O, Q, U, W and Z are not used) and "N" is a digit. The first character indicates a province, territory, or a major geographic region contained entirely within a province's boundaries. Report Canada Postal Codes only. The postal code would be reported if the following conditions exist: Other Country Flag is coded "N" - No; Homeless Flag is coded "N" - No; and Postal Code Known Flag is coded "Y" - Yes. If Other Country Flag or Homeless flag is coded "Y" - Yes a postal code would not need to be reported. Implementation Consideration Permissible Data Element Value HISCA Alias Approved Canada postal code from Canada Post Postal Code 2010 Government of Alberta 34 of 103

35 Data Element Name Postal Code of Patient's Current Residence Known Flag Address Postal Code of Patient's Current Residence Known Flag indicates if the postal code of the patient's usual residence is available. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline Report "N" - No if the patient's postal code is unknown and cannot be reported. Implementation Consideration Permissible Data Element Value Y - Yes N - No HISCA Alias 2010 Government of Alberta 35 of 103

36 Data Element Name Homeless Flag Address Homeless Flag is an indicator noting that the patient has no permanent or temporary residence at the time of admission. A shelter would not be considered a residence. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline In the event that the patient provides the address for a shelter, drop in centre, or next of kin when they re not residing with them, Y - Yes would be reported. Implementation Consideration Permissible Data Element Value Y - Yes N - No HISCA Alias 2010 Government of Alberta 36 of 103

37 Data Element Name Other Country Flag Address Stakeholder Demographic Version 2.2 Other Country Flag indicates that the patient's usual residence is a country other than Canada. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline People who are visiting on a work or student visa would be considered a resident of Canada if it is known that they have a permanent address and would be reported as No. Implementation Consideration Permissible Data Element Value Y- Yes N - No HISCA Alias 2010 Government of Alberta 37 of 103

38 Parent Component Name Service Episode Program Service Episode Service Program Start Date Mental Health Program Cardinality The date when the Program is associated with the Service Episode. Business Rule/Coding Guideline 2010 Government of Alberta 38 of 103

39 Data Element Name Service Program Start Date Service Episode Program Service Program Start Date is the date that the patient began treatment in a mental health program within the facility. Date Information Exchange Length 8 Mask YYYYMMDD Conditional Cardinality 0:1 Business Rule / Coding Guideline This data element is reported in conjunction with the data element "Mental Health Program." Report the Service Program Start Date as the date that the patient began treatment in a mental health program. Report a Service Program Start Date for each program the patient is treated in during a reporting period. Implementation Consideration Permissible Data Element Value HISCA Alias Valid Date (YYYYMMDD) Service Program Unit Start Date 2010 Government of Alberta 39 of 103

40 Parent Component Name Mental Health Program Service Episode Program Mental Health Program Cardinality Within a Mental Health Inpatient Service Episode the identification of a Mental Health Program under which services will be provided. One Mental Health INpatient Service Episode will be associated with a minimum of one Mental Health Program identified at time of admission Business Rule/Coding Guideline 2010 Government of Alberta 40 of 103

41 Data Element Name Mental Health Program Mental Health Program Mental Health Program is the category of integrated services provided to the patient. Character Information Exchange Length 2 Mask AA Mandatory Cardinality 1:1 Business Rule / Coding Guideline Report all mental health programs that the patient receives treatment in during a reporting period. Report young offenders as 03 - Forensic Psychiatry. Implementation Consideration Permissible Data Element Value HISCA Alias 01 - Brain Injury Rehabilitation 02 - Adult Psychiatry 03 - Forensic Psychiatry 04 - Geriatric Psychiatry Program Code 2010 Government of Alberta 41 of 103

42 Parent Component Name Inpatient Status Service Episode Psychiatric Status Public Guardian Code Responsibility for Payment Forensic Legal Status Cardinality At a point in time for a Stakeholder admitted as Mental Health Inpatient to a Facility identification. Business Rule/Coding Guideline 2010 Government of Alberta 42 of 103

43 Data Element Name Psychiatric Status Inpatient Status Psychiatric Status identifies if the patient is voluntary (non-certified) or involuntary (certified under the Mental Health Act). Character Information Exchange Length 2 Mask AA Mandatory Cardinality 1:1 Business Rule / Coding Guideline The following certificates are considered 24-hour hold certificates and are used to convey a person to a facility for examination: Form 1 - Admission Certificate (A Form 1 Admission Certificate once issued in the community authorizes conveyance of up to 72 hrs. Once at the facility, this certificate permits detention up to 24 hrs following arrival). Form 3 Order to Return a Formal Patient to a Facility (if the formal patient leaves the facility without permission AWOL a Form 3 is issued for a peace officer to return the patient to a designated facility. If the existing certificates have expired during the leave of absence, the person is deemed to be a person in respect of whom one admission certificate has been issued and they may be detained up to 24 hours upon return to a designated facility. Form 4 - Certificate of Transfer Into Alberta (Form issued by the Minister or Designate), authorizes a peace officer to apprehend the person and convey them to a facility for examination and detention at a facility for examination up to 24 hours. Form 8 Mental Health Warrant or Form 9 Extension of Warrant (A warrant is valid up to 7 days and may be extended for another 7 days and provides authority for any peace officer to apprehend that individual for conveyance to a designated facility for examination). The Mental Health Warrants expire 24 hours from the time the person arrives at the facility. Form 10 - Statement of Peace Officer on Apprehension authorizes 2010 Government of Alberta 43 of 103

44 conveyance to a designated facility for examination. Form 10 expires 24 hours from the time the person arrives at the facility. Formal status: 2 Admission certificates are required in order for a patient to become formal. A patient may be detained under one Admission Certificate but is not a formal patient until both are completed. Issuance of two Admission Certificates (Form 1). The second certificate must be issued within 24 hours of the issuance date and time of the first certificate; or Two Renewal Certificates (Form 2). The Renewal Certificates do not need to be issued within 24 hours of each other but both must be issued prior to the expiry date and time of the previous set of certificates. Note: Certificates should be completed in accordance with the Mental Health Act. Implementation Consideration Permissible Data Element Value 01 - Issuance of one 24-hour hold certificate which could include conveyance to a facility Formal status: 2 Admission certificates are required in order for a patient to become formal. A patient is involuntary under one Admission Certificate but not formal until both are completed. *Issuance of two Admission Certificates (Form 1). The second certificate must be issued within 24 hours of the issuance date and time of the first certificate; or *Two Renewal Certificates (Form 2). The Renewal Certificates do not need to be issued within 24 hours of each other but both must be issued Prior to the expiry date and time of the previous set of certificates Issuance of one 24-hour hold (see number 1 for types of certificates) plus the issuance of two Admission Certificates or two Renewal Certificates Voluntary HISCA Alias Psychiatric Status Code 2010 Government of Alberta 44 of 103

45 Data Element Name Public Guardian Code Inpatient Status Public Guardian Code Identifies if there is a public guardian appointed for the patient. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline The Public Guardian Code must be reported in the reporting period in which it is assigned. Implementation Consideration Permissible Data Element Value HISCA Alias Y - Yes, for public guardian appointed N - No, for no public guardian U - Unknown, not asked or not available (collected) at source. Public Guardian Code 2010 Government of Alberta 45 of 103

46 Data Element Name Responsibility for Payment Inpatient Status Responsibility for Payment code identifies the primary source responsible for payment of health service(s) rendered. Character Information Exchange Length 2 Mask AA Mandatory Cardinality 1:1 Business Rule / Coding Guideline In the event that multiple sources are responsible for payment of the health services provided, report the code that identifies the primary payment source. If the source of payment for a homeless patient is unknown, report "01" - Alberta Government. Implementation Consideration Permissible Data Element Value HISCA Alias 01 - Alberta Government 02 - Worker s Compensation Board (WCB) 03 - Other Provincial or Territorial Government (resident of Canada) 04 - Federal Government - Veteran Affairs Canada (VAC) 05 Federal Government - First Nations and Inuit Health Branch (FNIHB) 06 - Federal Government - Other (RCMP, Department of National Defence, Penitentiary Inmates, Immigration) 07 - Canadian resident Self pay 08 Other Country Resident, Self-pay 99 - Responsibility for payment unknown/unavailable Responsibility for Payment Code 2010 Government of Alberta 46 of 103

47 Data Element Name Forensic Legal Status Inpatient Status Forensic Legal Status identifies the status of the patient according to the Criminal Code. Character Information Exchange Length 1 Mask A Mandatory Cardinality 1:1 Business Rule / Coding Guideline The listed values fall under the Criminal Code of Canada. Patients may, however, be admitted simultaneously under Form 1 or Form 6 of the Mental Health Act but the Criminal Code of Canada value takes precedence. Implementation Consideration Permissible Data Element Value 1 - Not Criminally Responsible 2 - Not Fit To Stand Trial 3 - Remand 4 - Serving Prisoner 5 - Treatment Order (Judicial) 9 - Not Applicable HISCA Alias Forensic Legal Status Code 2010 Government of Alberta 47 of 103

48 Parent Component Name Health Diagnosis Service Episode Diagnosis DSM-IV-TR Description Code DSM-IV-TR AXIS Code ICD-10-CA Code ICD-10-CA Prefix Code DSM-IV-TR GAF Score Cardinality For a Mental Health Inpatient an assessment of the Stakeholder's well being expressed against known classification schemes An initial assessment is made when the Stakeholder is admitted to the Facility. Additional assessments may be made at any time while the Stakeholder is a Mental Health Inpatient Business Rule/Coding Guideline 2010 Government of Alberta 48 of 103

49 Data Element Name Diagnosis Health Diagnosis CIHI DAD Abstracting Manual Diagnosis describes the significance of a reported diagnosis and, in some instances, provides information on when the diagnosis was established (e.g. before admission or after admission) Character Information Exchange Length 1 Mask A Optional (Changed from Conditional to Optional to facilitate reporting data element for 2009/2010) Cardinality 0:1 Business Rule / Coding Guideline This data element must be assigned to each reported diagnosis for DSM-IV-TR Axis Codes 1 through 4. Refer to the Canadian Institute for Health Information (CIHI) Discharge Abstract Database reporting manual and Canadian Coding Standards for ICD-10-CA and CCI for further information on assigning Diagnosis s. Note: For 2009/2010 this Conditional reporting rule will not be enforced. Reporting of this data element is optional. Implementation Consideration Permissible Data Element Value HISCA Alias M - Most Responsible Diagnosis (MRDx) 1 - Pre-admit Comorbidity 2 - Post-admit Comorbidity 3 - Secondary Diagnosis 6 - A condition that is the manifestation of another condition and is responsible for the greatest length of stay and/or resources used during a hospitalization 9 - External Cause of Injury Diagnosis Code 2010 Government of Alberta 49 of 103

50 Data Element Name DSM-IV-TR Description Code Health Diagnosis Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Description Code identifies the textual description explaining the associated DSM-IV-TR code assigned to the patient. Character Information Exchange Length 5 Mask AAAAA Optional (Changed from Conditional to Optional to facilitate reporting data element for 2009/2010) Cardinality 0:1 Business Rule / Coding Guideline This data element must be assigned to each reported diagnosis for DSM-IV-TR Axis Codes 1 and 2. NOTE: For 2009/2010 this conditional reporting rule will not be enforced. Reporting of this data element is optional. Implementation Consideration Permissible Data Element Value HISCA Alias Valid values are found on the worksheet tab labelled "Permissible Values." DSM IV-TR Description Code 2010 Government of Alberta 50 of 103

51 Data Element Name DSM-IV-TR AXIS Code Health Diagnosis DSM-IV-TR AXIS Code is the categorization of mental health disorders based on the type of diagnosis. Psychiatric diagnoses are organized into five levels (axes) relating to different aspects of a disorder or disability. The axes include: Axis I: clinical disorders, including major mental disorders as well as developmental and learning disorders. Axis II: underlying pervasive or personality conditions as well as mental retardation. Axis III: acute medical conditions and physical disorders. Axis IV: psychosocial and environmental factors contributing to the disorder. Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children under the age of 18. See GAF Score data element for reporting Axis V. Character Information Exchange Length 1 Mask A Optional (Changed from Mandatory to Optional to facilitate reporting data element for 2009/2010) Cardinality 1:1 Business Rule / Coding Guideline A DSM-IV-TR AXIS Code must be assigned for each diagnosis that has been identified during the current reporting period. At this time, reporting of DSM-IV-TR-AXIS Code 5 (and GAF Score) is optional. A diagnosis reported in a previous reporting period does not need to be reported again in a subsequent reporting period. Note: For 2009/2010 this reporting requirement will not be enforced. Reporting of this data element is optional Government of Alberta 51 of 103

52 Implementation Consideration Permissible Data Element Value 1 - AXIS AXIS II 3 - AXIS III 4 - AXIS IV 5 - AXIS V HISCA Alias 2010 Government of Alberta 52 of 103

53 Data Element Name ICD-10-CA Code Health Diagnosis ICD-10-CA - CIHI International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, (ICD-10) with Canadian (CA) enhancements, is a classification scheme that contains codes for diseases, health problems, drugs and external causes of injury. Like conditions are grouped into a limited number of mutually exclusive statistical categories to facilitate easy data retrieval. Character Information Exchange Length 7 Mask AAAAAAA Conditional Cardinality 0:1 Business Rule / Coding Guideline Note: For 2009/2010 the following Conditional reporting rule will not be enforced. A code must be assigned for each Diagnosis that has been identified for DSM-IV-TR Axis Codes 1 through 4. A diagnosis reported in a previous reporting period does not need to be reported again in a subsequent reporting period. Note: Periods within ICD-10-CA codes are not reported. For example, the code F20.9 is reported as F209. Refer to CIHI Canadian Coding Standards for ICD-10-CA and CCI for further information on code selection and assignment. Consult with regional coding specialists for further information on Canadian coding standards. Note: For 2009/2010 the following Conditional reporting rule will be enforced. ICD-10-CA Code diagnosis must be reported if the Axis is not 5 or blank. Implementation Consideration Permissible Data Element Value HISCA Alias Valid ICD-10-CA Code ICD-10-CA Code 2010 Government of Alberta 53 of 103