HISO 10065:2017
Allied Health Data Set
Draft Standard
Draft standard for public comment
Released:18 September 2017
Closing date for submissions 3 November 2017
Allied Health Data Set Draft Standard for public comment
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Document information
HISO 10065:2017 Allied Health Minimum Data Set Standard is the minimum standard for the New Zealand Allied Health Professions operating in the physical health sector.
Published in xxxx2017 by the Ministry of Health
ISBNxx-x-xxxxxx-xx-x- (online)
The Health Information Standards Organisation (HISO) is the expert advisory group on standards to the Digital Advisory Board within the Ministry of Health.
HISO standards are posted on our website – see below.
Contributors
National Allied Health Informatics GroupNational Executive Directors of Allied Health Forum
Keeping standards up to date
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Standards may also be withdrawn. It is important that readers assure themselves they are using a current Standard, which will incorporate any amendments that may have been issued since the Standard was published.
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HISO welcomes suggestions for improvements, and encourages readers to immediately advise any apparent inaccuracies or ambiguities, using either email at , or write to:
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Copyright
Crown copyright ©. This copyright work is licensed under the Creative Commons Attribution-No Derivative Works 4.0 New Zealand licence. In essence, you are free to copy and distribute the work (including other media and formats), as long as you attribute the work to the Health Information Standards Organisation (HISO), do not adapt the work and abide by the other licence terms. To view a copy of this licence, visit
New Zealand Legislation
The following Acts of Parliament and Regulation have specific relevance to this standard. Readers must consider other Acts and Regulations and their amendments that are relevant to their own organisation, in the implementation or use of this standard.
- Health Act 1956
- Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996
- Health Information Privacy Code 1994
- Health Practitioners Competence Assurance Act 2003
- Privacy Act 1993 (revised 2008)
- Public Records Act 2005
- Retention of Health Information Regulations 1996
Related Standards and specifications
The key industry source standards referenced by this specification are:
- HISO 10029:2015 Health Information Security Framework
- ISO/IEC 11179 Information Technology – specification and standardization of data elements. Part 3: Basic attributes of data elements, second edition 2004Ministry of Health, National Health Index (NHI) -
See also: HISO 10046 Consumer Health Identity Standard
- Ministry of Health, Health Provider Index (HPI), includes the Common Person Number (CPN)
See also: HISO 10005:2008 Health Practitioner Index (HPI) Data Set
See also: HISO 10006:2008 Health Practitioner Index (HPI) Code Set
- Ministry of Health - Medical Specialty codes - National Collections - Common Code Tables/Health Specialty Codes (Sub set for Allied Health)
- Ministry of Health NNPAC 2015 v0.2 – Mode of delivery
- SNOMED CT: Systematized Nomenclature of Medicine – Clinical Terms
Contents
1Introduction
1.1Purpose
1.2Scope
1.3Future development
1.4Compliance
1.5Data element structure
2Data elements
2.1District Health Board
2.2Patient identifier (NHI number)
2.3Date of birth
2.4Allied Health occupation
2.5Role context
2.6Service location
2.7Medical specialty
2.8Referrer
2.9Clinician identifier – Responsible Authority members
2.10Clinician identifier – other practitioners
2.11Referral receipt date
2.12Prioritisation or Acceptance date
2.13Patient contact date
2.14Patient discharge date
2.15Type of contact
2.16Activity commencement
2.17Activity completion
2.18Encounter outcome
2.19Encounter outcome reason
2.20Destination
1Introduction
This standard sets out the minimum data needed to classify and describe clinical activity undertaken for patients by Allied Health services in New Zealand. It sets out to provide a meaningful data set to reflect the services and workflow key decisions that influence the patient’s journey alongside Allied Health care.
1.1Purpose
The Allied Health Standard (the Standard)is to ensure Allied Health services are identified, classified and recorded in a common way, enabling the generation of knowledge applicable to service development, national benchmarking and comparative service analytics. The Standard provides a level of detail that supports greater inter-district data sharing of information assisting Allied Health workforce planning and service delivery.
The standard records clinical activity regardless of the methodology adopted to achieve the outcome, i.e. direct manual/digital data capture systems or within the electronic health record. It is a minimum standard for outcome measures of Allied Health service input.
1.2Scope
TheStandard defines the minimum data required to be captured by Allied Health staff in District Health Boards in New Zealand to record patient-related clinical activity. The data will provide the standardisation required to enable services to be meaningfully benchmarked to each other. The core professional disciplines identified for inclusion at this stage are: Occupational Therapy, Physiotherapy, Social Work, Speech and Language Therapy and Dietetics/Nutrition.
The data set includes comprehensive level definitions of data applicable across the Allied Healthphysical health service spectrum. This is an ‘all age’ spectrum that includes inpatient, outpatient, emergency departments and community service settings.
To help guide the process of defining the data elements to be included within the collection, Allied Health work flow was defined to determine the main stakeholders or users of the data collected. The Australian National Allied Health Casemix Committee (NAHCC) (2001) has developed a matrix to highlight how the activity data needed at each stage of the Allied Health work flow (Input, Process, Output and Outcome) could vary by stakeholder (see Figure 1).
As patient/client interaction with the Allied Health disciplines are at the centre of this collection, the bare minimum and starting point for this collection focuses on client and departmental stakeholders (i.e. axis A and B in Figure 1). Once this data set is standardised it is easier to build on the collection to provide the data required by the remaining stakeholders in later versions of the Allied Health Data Set Standard.
Figure 1: NAHCC Grid highlighting the various stake holders interested in Allied health workflow (NAHCC, 2001, pp15[1])
1.3Future development
This is Phase 1 of the Allied Health Data Set Standard. Phase 2 is to further engage andexpand the formalisation of the Allied Health Activity Data Set Standard, aligned to SNOMED CT. It is noted that the scope of professions aligned to and included within this Standard will continue to grow and require recognition as will the scope of organisational participation, i.e. PHOs and other agencies.
1.4Compliance
There are a large number of valued stakeholders interested in Allied Health information. Moving towards a single standardised data set for five different professional disciplines nationally will require a significant paradigm shift in how information is collected. It is recognised that the transition to obtain all elements of this data set will take time, particularly in negotiation with any industry partners involved in the systems in place.
1.5Data element structure
Each data element has been defined according to a set of metadata components that are based on ISO Standard 11179 Information Technology – Specification and standardization of data elements, 2003. Most components such as definition, data type, representational form, data domain, etc., describe essential features of the structure of a data element. Some components such as collection methods and comments describe additional, non-essential features and may be left blank where appropriate.
Definition / A statement that expresses the essential nature of the data element and its differentiation from all other data elements.Source standards / Details of established data definitions or guidelines for data elements that have been cited in this Standard.
Data type / Alphanumeric (X), Alphabetic (A), Numeric (N, numbers including decimals), Boolean (Y/N or checkbox on/off).
Date data structure / Century (CC) Year (YY), Month (M) and Day (D). Full date representation is CCYYMMDD.
Time data structure / Hour (H), Minute (M) and (S) Second. Time is recorded using the 24 hour clock.
Representational class: / For A, N and X, use code, free text, value or identifier. For date use full, partial or both date types.
Field size: / Maximum number of characters that may be recorded in the field.
Representational layout: / The arrangement of characters in the data element. For example, ‘A(50)’ means up to 50 alphabetic characters; ‘NNAAAA’ means numeric, numeric, alpha, alpha, alpha, alpha.
Data domain: / The valid values or codes that are acceptable for the data element. The data elements contained in this standard are dates, free text or coded. For each data element that is coded, a code value is provided in the Allied Health Code Set, as well as a description and an explanation of the code value. The valid values or codes contained in this standard are principally New Zealand values, although, in certain cases, international codes, e.g. Health Round Table, are used. Free text fields also allow international data to be received and stored.
Guide for use: / Additional guidance to inform the use of the data element.
Verification rules: / Quality control mechanisms that preclude non-valid codes from the data element.
2Data elements
This section describes the required set of Allied Health service and activity data elements. Together, these elements identify and describe a period of active care, from start to completion, between the Allied Health professional and the patient.
Note: All data elements described in this standard are Mandatory.
2.1District Health Board
2.2Patient identifier (NHI number)
2.3Date of birth
2.4Allied Health
2.5Role context
2.6Service location
2.7Medical specialty
2.8Referrer
2.9Clinician identifier – Responsible Authority members
2.10Clinician identifier – other practitioners
2.11Referral receipt date
2.12Prioritisation or Acceptance date
2.13Patient contact date
2.14Patient discharge date
2.15Type of contact
2.16Activity commencement
2.17Activity completion
2.18Encounter outcome
2.19Encounter outcome reason
2.20Destination
2.1District Health Board
The agency code for a District Health Board (DHB) under whose jurisdiction the patient receives the care provided
Definition: / An agency code to uniquely identify an individual District Health Board. The value is combined with local service coverage, regional information and a team name to avoid ambiguity in identification.Source standards: /
Data type: / Numeric / Representational class: / Identifier
Field size: / Max: 4 / Representational layout: / NNNN
Data domain: / List of DHBs
Guide for use: / The DHB agency code is assigned by the Ministry and is historically used to identify an organisation, institution or group of institutions in the Ministry legacy systems (NMDS, NBRS, MHINC et al).
Verification rules: / Valid code set value only.
2.2Patient identifier (NHI number)
Definition: / A unique seven character identification number assigned by the NHI system to a patient to whom the care is being providedSource standards: / HISO 10046 Consumer Health Identity Standard
See also:
Data type: / Alphanumeric / Representational class: / Identifier
Field size: / Max: 7 / Representational layout: / AAANNNC
Data domain: / Valid NHI number only
Guide for use: / Only the NHI system generates a new unique number key (the NHI number) that is assigned to a patient identity. NHI numbers are not re-used once assigned to a patient identity. Where more than one number exists for a patient identity, one number is declared ‘live’ and all other numbers are made ‘dormant’ and attached to the live record. The NHI number is the primary key for patients’ records.
Verification rules: / A – an alpha character only but not ‘I’ or ‘O’
N – a number
C – a number, which is calculated using check digit Modulus 11
NHI structure details and check sum modulus tables are provided in HISO 10046 Consumer Health Identity Standard, Appendix C.
2.3Date of birth
Definition: / The Date of birth (DoB) provided by the patient on presentation to indicate the day, month and year of their birth.Source standards: / HISO 10046 Consumer Health Identity Standard
Data type: / Date / Representational class: / Full date
Field size: / Max: 8 / Representational layout: / CCYYMMDD
Data domain:
Guide for use: / Provides the ability to match data across databases, having both NHI and DOB ensures accurate and robust cross referencing.
Verification rules: / The date of birth must be a valid day, month and year combination and cannot be in the future.
This date can be obtained from the patient but is to be confirmed with that held within the NHI system.
2.4Allied Health occupation
Definition: / The professional occupation or discipline name of the service provided, i.e. social work or indication of an event where merged services were provided e.g. transdisciplinarySource standards: / SNOMED CT
Aligned to Australia New Zealand Classification of Occupations (ANZSCO)
Data type: / Numeric / Representational class: / Code
Field size: / Max: 18 / Representational layout: / N(18)
Data domain: / Descriptor / SNOMED
Concept ID / SNOMED preferred term
Physiotherapist / 36682004 / Physiotherapist
Occupational therapist / 80546007 / Occupational therapist
Speech and language therapist / 159026005 / Speech and language therapist
Social Worker / 106328005 / Social worker
Dietician/public health nutritionist / 106291005 / Dietician AND/OR public health nutritionist
Transdisciplinary / NOTE:An appropriate SNOMED Concept ID and description is still to be established.
.
Guide for use: / Only six options are available in the first phase.
Verification rules: / Valid code set value only.
2.5Role context
Definition: / The context of role (the skill and professional capacity of the staff member) undertaking the service.Source standards: / SNOMED CT
Data type: / Numeric / Representational class: / Code
Field size: / Max: 18 / Representational layout: / N(18)
Data domain: / Descriptor / SNOMED
Concept ID / SNOMED preferred term
Professional / 309398001 / Allied health professional
Allied Health Assistant / NOTE: an appropriate SNOMED Concept ID and description is still to be established
Student / 65853000 / Student
Guide for use: / ‘Professional’ – a staff member with tertiary qualification and accreditation to practice using their specified occupational title. As per 2.4 above.
‘Allied Health Assistant’ – a staff member not formally accredited with an allied health qualification.
‘Student’ – a person registered to an accredited training programme, not formally registered to practice.
Verification rules: / Valid code set value only.
The default value is ‘Professional’.
2.6Service location
Definition: / Where the patient is located at the time of service provision.Source standards: / SNOMED CT
Data type: / Numeric / Representational class: / Code
Field size: / Max: 18 / Representational layout: / N(18)
Data domain: / Descriptor / SNOMED
Concept ID / SNOMED preferred term
Inpatient environment / 440654001 / Inpatient environment
Emergency Department / 225728007 / Accident and Emergency department
Patient’s residence / 394778007 / Client's or patient's home
Community location (i.e. school, worksite) / 285202004 / Community environment
Guide for use: / The service location identifies and contributes to information about service provision aligned to patient need. It does not capture information about the facility that the service staff operate from.
Verification rules: / Valid code set value only.
2.7Medical specialty
Definition: / A descriptorof specialty or scope of service that definesthe most relevant care provided to the patient.Source standards: / Ministry of Health - National Collections - Common Code Tables/Health Specialty Codes
Data type: / Alphanumeric / Representational class: / Code
Field size: / Max: 3 / Representational layout: / ANN
Data domain: /
Guide for use: / Selection is based on which speciality the patient has been aligned to at point of care or which is most relevant to the scope of care being provided.
Selection of a medical specialty will create greater visibility of staffing resource and activity by enabling association to a specified Allied Health occupation and role.
Verification rules: / Valid code set value only.
2.8Referrer
Definition: / Identification of the source of referral requested Allied Health service provision, i.e. professional group typeSource standards: / SNOMED CT
Data type: / Numeric / Representational class: / Code
Field size: / Max: 18 / Representational layout: / N(18)
Data domain: / Descriptor / SNOMED
Concept ID / SNOMED preferred term
General Practitioner / 62247001 / General practitioner
Specialist Medical Officer / 158967008 / Consultant physician
Nurse / 106292003 / Nurse
Midwife / 75271001 / Professional midwife
Allied Health practitioner / 309398001 / Allied Health professional
Dentist / 106289002 / Dentist
Self / 306098008 / Self-referral
Guide for use: / Aligned to the Ministry of Health national patient flow collection (July 2016). Note: this information is limited to the professional context and does not include the referrer’s personal identification or responsible authority.
Verification rules: / Valid code set value only.
2.9Clinician identifier–Responsible Authority members
A unique identifying number pertaining to the health care provider that is delivering the service where that health care practitioner IS a member of a Responsible Authority as set out in the Health Practitioners Competence Assurance Act 2003[2].