Minimum Dataset

div class="documentDescription">The following tables come from an upcoming supplement on HIV/AIDS care. Discussion of these tables is available in our forum.

TABLE 1: Consumers of data and their activities and data needs

Data Consumer	Activities Supported	Data Needs
Clinic management (clerks, etc.)	Registration, scheduling, billing	Unique patient identifiers Individual patient demographics Family identifiers Clinic/program identifiers Unique provider identifiers Financial data payment program identifiers, charges, payments
Clinicians (physicians, physician extenders, nurses, pharmacists, therapists, counselors, etc.)	Diagnosis, treatment, prevention	Medical history risk/exposure, symptoms. diagnoses Physical examination vital signs, physical findings Diagnostic tests HIV-specific blood tests (CD4, viral load) general blood/urine tests, imaging tests Diagnoses HIV/AIDS status, class/severity of illness * HIV/AIDS associated conditions * prevalent unassociated conditions Treatment drugs, procedures Counseling
Practice managers	Scheduling, inventory control, quality improvement	Visit numbers, types Unique provider identifiers Provider characteristics Treatment drugs, procedures Patient disposition Patient outcomes
District/regional/national program administrators	Program development, program monitoring, reporting to funders (e.g., ministry of health, government officials)	Patients receiving care non-HIV-infected, HIV-infected, AIDS * Visit numbers outpatient, inpatient (including length of stay) Treatment categories antiretroviral drugs, antibiotics Patient outcomes Program costs Personnel involved
Funding agencies	Oversight, program productivity	Patients receiving care non-HIV-infected, HIV-infected, AIDS * Visit numbers outpatient, inpatient (including length of stay) Treatment categories antiretroviral drugs, antibiotics Patient outcomes Program costs
* HIV=human immunodeficiency virus, AIDS=acquired autoimmune deficiency syndrome

TABLE 2: The Minimum Data for an Electronic Medical Record Supporting HIV/AIDS Care

Data Category	Data Element		Data Type	Who Records It
Registration, scheduling, and practice management	Unique patient identifier		Alphanumeric with check digit	Registration clerk
	Patient Name		Text	Registration clerk
	Patient address		Text	Registration clerk
	Visit date		Date	Registration clerk
	Site of care (clinic, home, etc.)		Coded	Registration clerk
	Demographics (birth date, sex, race/tribe)		Coded	Registration clerk
	Family identifier		Numeric	Registration clerk
	Unique provider identifiers		Alphanumeric with check digit	Physician/extender,* nurse, clerk
	Payment program identifiers		Coded	Financial officer, clerk
	Charges, payments		Numeric, financial	Financial officer, clerk
Clinical	History
		symptoms	Coded	Physician/extender, nurse
		prior diagnoses	Coded	Physician/extender, nurse
		prior treatment (drugs, procedures)	Coded	Physician/extender, nurse
	Physical examination
		vital signs (weight, height, pulse, etc.)	Numeric	Physician/extender, nurse
		physical findings	Coded	Physician/extender, nurse
	Diagnostic tests
		ordering provider	Alphanumeric with check digit	Physician/extender, nurse, clerk
		test ordered	Coded	Physician/extender, nurse, clerk
		clinical laboratory test results	Coded, numeric	Physician/extender, nurse, clerk
		imaging test results	Coded	Physician/extender, nurse, clerk
	Treatment
		antiretroviral drugs	Coded	Physician/extender, nurse, pharmacist
		other antibiotics, other drugs	Coded	Physician/extender, nurse, pharmacist
		drugs dispensed	Coded	Pharmacist
		procedures	Coded	Physician/extender, nurse
		physical therapy	Coded, free text	Physician/extender, nurse, therapist
		counseling/family planning	Coded, free text	Physician/extender, nurse, counselor
	Visit diagnoses		Coded	Physician/extender, nurse
	Medication adherence		Coded, numeric	Physician/extender, nurse, pharmacist
	Disposition: clinic referral, hospitalization		Date, coded	Physician/extender, nurse, clerk
	Death (date, cause)		Date, coded	Physician/extender, nurse, clerk
* “Physician/extender” refers to either a physician or a physician’s assistant (called a “clinical officer” in many developing countries), nurse practitioner, physician trainee (medical student or resident), etc.

Table 3: Examples of Data Elements for a Minimum Dataset for HIV/AIDS Care

Data Class	Data Element	Format and Units	Range of Values
Demographics	Birth date	DD/MM/YYYY	< 01/01/1900 to today’s date
	Birthplace: Village/City Province Country	Text	Variable
		Text	From list
		Text	From list
	Sex	Coded	Male, Female
	Tribe	Text	From list
History	HIV-related diagnoses	Coded: ICD10	B20-B24, F02.4, R75, Z21
	Comorbid diagnoses	Coded: ICD10	From ICD10 codebook
	Medications	Coded	From available drug list
	Treatment adherence	Coded	Likert scale (excellent to poor)
		Semi-quantitative	Ranges: % of prescribed doses taken
		Numeric: Scale score	Depends on scale (e.g., Morisky) *
		Numeric: Pill count	Percent of prescribed doses taken
	Alcohol use	Coded	Use: Yes, No; Abuse: Yes, No
		Numeric: drinks/day	0 to > 10
		Numeric: scale score	Depends on scale (e.g., AUDIT) ^†
	WHO class	Numeric: ordinal scale	1, 2, 3, or 4
Physical Examination	Blood pressure, systolic	Numeric: mmHg	30 to >300
	Blood pressure, diastolic	Numeric: mmHg	30 to >300
	Heart rate	Numeric: beats/min	0 to >200
	Weight	Numeric: kg	0.5 to >300
	Temperature	Numeric: ^oC	30 to 44
	Various physical findings	Coded	From a local data dictionary ^‡
Laboratory: HIV-Specific	HIV antibody	Coded	Positive, Negative
	CD4 cell count	Numeric: ells/mm³)	0 to >1000
	CD8 cell count	Numeric: cells/mm³)	0 to >1000
	HIV viral load	Numeric: Copies/mm³	0 to >1,000,000
Laboratory: HIV Monitoring	Alanine aminotransferase	Numeric: IU/L	0 to 35
	Albumin, serum	Numeric: g/L	0 to 10
	Hemoglobin, blood	Numeric: g/L	1 to 25
	Leukocytes, blood	Numeric: cells/mm³	0 to >100,000
	Platelets, blood	Numeric: count/mm³	0 to >1,000,000
	Lymphocytes	Numeric: count/mm³	0 to >10,000
	Creatinine	Numeric: mg/dL	0.1 to >25
Imaging	Chest x-ray findings	Coded	From a local data dictionary
Imaging	EKG findings	Coded	From a local data dictionary
* See reference 22 ^† See reference 23 ^‡ See references 17 and 24.

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Minimum Dataset