Inventory of Health Care Information Standards. Wright State University College of Nursing and Health


III. ANSI Accreditation

The Patient Core Data Set development organization is not ANSI accredited. PCDS development is complete and future efforts include seeking national acceptance and accreditation.


IV. Name of Standard:

Patient Core Data Set

V. Contact for more information:

Alice Renner

Wright State University

College of Nursing and health

3640 Colonel Glenn Highway

Dayton, OH 45435

Phone: 937-775-2591

Fax: 937-775-4571


VI. Description of Standard:

Through support of the Agency of Health Care Policy and Research, Public Health Service, Blue Chip Computers Company in collaboration with Wright State University-Miami Valley College of Nursing and Health completed SBIR research for a comprehensive design of an Integrated Patient Information System (IPIS). [ Blue Chip Computers Company, Inc., Integrated Patient Information System, SBIR Grant, Contract Number 282-94-2039, Funded by DHHS Public Health Service, Agency for Health Care Policy and Research] Research findings confirmed the hypothesis that the inadequacy of current patient information systems can be attributed to the following fundamental causes: (1) The lack of uniform standards of patient minimum data sets; (2) The lack of systems interoperability and overall data integration in existing patient information systems; and (3) The lack of continuity of the patient health records and data exchange capability. The Wright State University consultants undertook the development of a Patient Core Data Set (PCDS) in response to the lack of uniform standards of minimum data sets and lack of standards in data transfer for continuity of care. The PCDS consists of a common core of data elements to be collected for all patients receiving health care. The PCDS provides the uniform standard of electronic patient data exchange among different health care institutions needed by a variety of users through compatibility with HL7 and ASTM electronic data interchange standards. The ability to exchange patient data accurately and timely can eliminate unnecessary duplication of tests, diagnoses and treatments.

(a) Objectives - The objectives of the Patient Core Data Set are to provide for the development of a longitudinal record of a patient's health and medical history through the use of a common set of 50 standard data elements with uniform definitions, and coding consistent with ASTM and HL7 standards. The data elements are divided into three areas: patient identification, service, and health.

The goal of the PCDS is to provide for a longitudinal record of a patient's health and medical history by making access to data from each health care episode easily accessible. Ideally following an episode, the core data set would be transferred to the patient's primary practitioner's office for updating the patient's record and/or to a regional or state data repository. However, until this becomes a reality, the PCDS residing in any facility could be easily queried upon request from another facility and because of the standardization could be expediently transferred from facility to facility.

(b) Function - The PCDS is essential information for a variety of health professionals, including clinicians, administrators, researchers, and policy makers. It is intended for transfer across all patient-care settings. As a core data set, the PCDS is not designed to be sufficient to meet the total data needs of any one user group. It is, however, recommended for inclusion in all computer-based patient records. All elements of the PCDS must be present to describe patient care across settings.

(c) User environment - The transfer of PCDS information allows comparability of patient data across clinical populations, health-care settings, and local, state and national regions. The PCDS is intended for outcome studies of health care effectiveness and clinical practice guideline usage. For example, clinical practice could be guided by information obtained from analysis of the effectiveness of a specific treatment modality. Patterns of service utilization and resource allocation can be investigated by health-care administrators. Furthermore, aggregate data collected on health risks and life-style behaviors have the potential to influence health policy decision making. Additional pieces of information may be needed beyond the PCDS by the various users, but should be obtained from the complete computerized patient medical record.

(d) Systems environment - This standard may be used from any operating system, network or hardware platform.

(e) Application function/domain completeness - The elements within the data set are complete.

(f) In what way(s) is this standard superior to other standards in this category/classification? - The PCDS is the only completed data set to date that incorporates the concept of "core data" for all patients across all health care settings. Core data is defined as data that meets the essential needs of multiple users, that is transferred across all patient-care settings, and that provides for continuity of care by forming the basis of a patient's computerized longitudinal medical record. Although various health constituencies have developed their own uniform data sets, these sets exist in isolation as each set has been created for specific purposes of the constituency that developed it. PCDS allows comparability of patient data across clinical populations, healthcare settings, and local, state and national regions. PCDS provides guidelines for both the user and the programmer. and includes the following information for each data element: name, number, definition, data uses, discussion, data type and field length, repetition, coding scheme, and relevant data standards and guidelines. The research team made a concerted effort to incorporate standards for computerized patient records in the PCDS and to make it compatible with HL7 and ASTM electronic data interchange standards. Future research efforts include mapping the PCDS data elements to elements in other common data sets, and revision over time based on field testing, other pertinent research, and developments in the field of health care data standards.

Readiness of Standard:

(a) Is it a guideline? - PCDS is a standard for building the longitudinal computerized patient record. The PCDS contains 50 data elements in three categories: patient identification, service, and health. PCDS includes the following information for each data element: name, number, definition, data uses, discussion, data type and maximum field length, repetition, coding scheme, and relevant data standards and guidelines. The exchange of information supports administration, clinical practice, research, and health policy making.

(b) Is it implementable? - The PCDS has been implemented in an integrated patient information system developed for a prenatal clinic and labor and delivery unit of a hospital.

(c) How can the standard be obtained? The standard can be obtained by contacting:

Alice Renner

Wright State University

College of Nursing and Health

3640 Colonel Glenn Highway

Dayton, OH 45435

Phone: (937) 775-2591

Fax: (937) 775-4571


(d-e) Does it require a separate implementation guide? - The data set does not require a separate implementation guide a copy of the PCDS provides information on implementation with each element. PCDS provides guidelines for both the user and the programmer and includes the following information for each data element: name, number, definition, data uses, discussion, data type and field length, repetition, coding scheme, and relevant data standards and guidelines.

(f) Is a conformance standard specified? - The PCDS specifies conformity, but recognizing that conformity will only come with a federal mandate, provides for alternate coding systems to be identified in the data exchange between computer systems. Standardization is more easily accomplished in the areas of patient identification and service elements, than in the clinical data area. Reporting of patient identification and service elements have been mandated for reporting for Medicare and Medicaid reimbursement since the 1980s, resulting in a degree of standardization. Clinical data, however, has been the last data to be computerized by healthcare facilities and much clinical data is still relegated to the paper record.

(g-h)Source of test tools?- None available to date.

(I) If the standard is under development, what parts of it are ready now? - The entire data set is available for use.

(j) What extensions are now under development? - Research continues on the relevance of each data element to the concept of "core data." The data set is dynamic and revision will be based on further national input and field testing which will result in additions or deletions of elements, or specificity of detail of an element. Other pertinent research and developments in the field of health care data standards will impact the PCDS.

(k) What are the major milestones towards standards completion?- The following are major activities in the research and development of the PCDS toward making it ready for consideration as a standard:

The development team researched and evaluated existing health care data sets and used this as a basis for forming the PCDS. During development of the PCDS, a content validity survey was conducted to obtain both local and national input on the data set, evaluate the relevance of the elements to the data set and obtain recommendations for additions and changes to the data set. The evaluation tool that was used is based on the article: Lynn, M.R. (1986) Determination and quantification of content validity. Nursing Research. 35(6), 382-385. The tool provides determination of the content representativeness or content relevance by the application of a two-stage (development or judgment) process. Quantification of content validity is achieved through the use of the index of content validity (CVI) which is determined from the ratings of the relevance of the data elements using a 4-point ordinal rating scale. The content validity surveys provided much valuable information for the development of the data set.

Because the data set had to be useful to a variety of users including administrators, clinicians, researchers, and health policy makers, the consultants sought experts from these areas with proficiency in health care informatics. Fourteen national experts participated in the workgroup sessions held June 27-29, 1996. The experts included the Executive Director of the Medical Records Institute and chair of the national committees: ASTM E31.20, Standards Committee on Electronic Signatures in Health Care and the American National Standards Institute – Task Force on International Cooperation; the chairman of ASTM E31 Healthcare Informatics; the chair of ASTM E31.12 Computer-Based Records committee; the chair of Health Level 7; an expert and consultant on the Long Term/Home Health Delivery System and author of the Saba Home Health Care Classification System, nurse researchers involved in standards development for nursing data elements for nursing interventions and outcomes; representatives form the Agency for Health Care Policy and Research; the Joint Commission on Accreditation of Healthcare Organizations; experts in outcomes research, a developer of an enterprise computer system for several hospitals and clinics; and health policy researchers.

The Wright State consultants are also investigating the formation of an American Society for Testing and Materials (ASTM) committee for the PCDS similar to the committee for the computerized patient record. The data set was developed to be compatible with the E31 Health Informatics standards and these standards are referenced in the data set.

Because the HL7 has become the defacto standard for data exchange in health care informatics, compatibility with Health Level 7 (HL7) protocol for health information exchange was also important in the development of the PCDS. The consultants plan future work with HL7 experts to identify the corresponding HL7 segment data fields with the PCDS data fields. Inclusion of the information on coding according to the standards for data interchange will help acceptance and use of the data set.

What are the projected dates for final balloting and/or implementing?


Indicator of Market Acceptance:

The data set development has just been completed and the set has been included in a report to the Agency for Healthcare Policy and Research. The PCDS has not been made distributed to date.

Level of Specificity:

(a) How detailed is your standard? - The PCDS has been developed to meet specific needs of a variety of health care professionals including clinicians, administrators, researchers, and health policy makers.

(b) How detailed is the framework and its level of granularity? - A separate implementation guide is not available at this time. Each data element is described in detail with a discussion of the conceptual basis or any other specific aspects of data collection not covered in the documentation for that element. The level of detail of the clinical elements in particular may be increased in future revisions of the data set if additional testing indicates that the detail is not sufficient to meet the crucial needs of clinicians.

(c) Does the standard reference or assume other standards to achieve specificity? -

The PCDS does reference other standards to achieve specificity. It is compatible with and references ASTM and Health Level 7 protocol standards for data transmission of information collected for the data set.

(d-h) If it includes or assumes code sets, which ones are they and how are the code sets acquired? - The PCDS uses the following code sets:


Health Care Procedure Codes (HCPCS)


ICD-9-CM Procedure Codes

National Center for Health Statistics

CPT Codes - Physicians Current

Procedure Terminology

American Medical Association

Patient Identification/Occurrence Codes

National Uniform Billing Committee

Health Level 7

Health Level Seven

Logical Observation Identifier

Names and Codes (LOINC)

Duke University

ASTM E1238-94 and E1384-96

American Society for Testing Materials

National Drug Code


World Health Organization Drug Records

World Health Organization

North American Nursing

Diagnosis Association (NANDA)

North American Nursing

Diagnosis Association

Nursing Intervention Classification System

University of Iowa (Mosby Publishing Co.)

Nursing Outcomes Classification System

University of Iowa

National Provider Identification File


Systematized Nomenclature of Medicine (SNOMED)

College of American Pathology


X. Relationships with other standards

(a-c) Identify other standards and the relationships with other standards:- The standards that have been referenced in the PCDS are as follows:

ASTM 1238-94

ASTM 1384-96

Health Level 7

The coding of the data elements in the PCDS and suggested format for electronic exchange of the information are consistent with these standards.

Identifiable Costs:

(a) Cost of licensure - No license is necessary at this time to use the PCDS

(b) Cost of acquisition - The cost of reproducing the data set and distribution costs have not been determined yet, but should be minimal.

(c) Cost/timeframes for education and training - The cost/timeframe for education and training will depend upon the individuals and the skill levels of the individuals. The coding of the database is discussed in the data set and only the most widely used code sets have been incorporated in the data set

(d) Cost and timeframes for implementation - The cost/timeframe for implementation depends upon the systems capability, hardware platform, and internal resources available for implementation.