inpatient care, and the two federal cancer registry systems—Surveillance, Epidemiology, and End Results system (SEER) and the National Program of Cancer Registries (NPCR)—collect some information from medical and laboratory records. Thus, the review in this chapter of the collection of data on race, ethnicity, SEP, and acculturation and language use by private record systems has implications for other data systems described in the previous chapters.

Hospitals collect information on patients during the admissions process. These data typically include background information on the patient (this information may include race, ethnicity, income, and/or education level); initial health conditions and symptoms, health insurance coverage, if any (including coverage through Medicaid, Medicare, or SCHIP); and services and treatment received while at the hospital. Information is kept on the patient’s treatment during the hospital stay and compiled in a document that is completed when the patient is discharged, called the discharge abstract.3 Many of these discharge abstracts are forwarded to state health agencies or to the federal government for statistical purposes. The National Hospital Discharge Survey collects medical records from a sample of nonfederal (which excludes military and VA hospitals), short-stay hospitals. The Healthcare Cost and Utilization Project collects hospital discharge data from 33 state organizations and generates a national data set, the Nationwide Inpatient Sample (NIS), which is a 20 percent sample of hospitals in the nation, and a State Inpatient Database (SID), which represents all acute-care discharges in the participating state.

There is some standardization of billing forms that hospitals use to bill for services provided. These include the Uniform Bill (UB92), which is currently used by hospitals, nursing facilities, and clinics to bill third-party insurers and government programs such as Medicaid, and the HCFA 1500, which is used to bill for professional services, such as physician or laboratory visits.

Health insurance data on individuals are collected when the individual both applies for health insurance (enrollment) and utilizes a health care service covered under the health insurance plan. Enrollment data include basic demographic information and may include medical history, employment status, and ability to pay premiums. Insurance claims forms typically include member (patient) identification information, dates of services, diagnoses, procedure codes, and billed charges.

Data collected from medical groups, physicians’ offices, and group practices are similar to those collected by hospitals. They may include


Information from birth certificates, disease reports, and cancer registries is also collected by hospitals; these were discussed in previous chapters.

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