Decision Support System (DSS)

The Decision Support System (DSS) is a set of programs that uses relational databases to provide information needed by managers and clinicians, including the cost of specific patient care encounters. DSS has been implemented throughout the U.S. Department of Veterans Affairs (VA) healthcare systems. All medical centers should have DSS financial data on healthcare services provided after October 1, 1998.  The most current 3 years of data are stored in the DSS production system, but VA researchers can generally access only the DSS National Data Extracts, national files that are located at the VA national computer facilitiy in Austin, Texas.  National DSS files characterize the cost of VA health care encounters provided since 2001.

How Costs Are Determined in DSS

DSS extracts costs from the VA payroll and general ledger. These are assigned to departments based on periodic reports made by managers, who assign costs of the six categories of expense to departments. Some sites use time reports and accounting data instead of managerial reports to assign costs to departments. The calculation of department costs from the managerial estimates, payroll, and general ledger data is done by the DSS program called the Account Level Budgeter (ALB).

Overhead (the cost of departments that do not produce patient care) is distributed to patient care departments using a step-down method. Direct cost or the number of square feet of occupied space are used as the basis of the distribution.

Costs of intermediate products are then determined. Examples of intermediate products are: chest x-rays, units of blood, 15-minute clinic visits, or days of stay in the intensive care unit. They are called intermediate products to distinguish them from the final product--a patient encounter, which is a bundle of intermediate products.

DSS relies on pre-existing VA databases for information on what care was provided and which patients utilized it. The Veterans Health Information Systems and Technology Architecture (VISTA) is the means by which VA records clinical data and documents healthcare encounters. Formerly known as the Decentralized Hospital Computer Program (DHCP), this system includes modules that record data from laboratory, pharmacy, radiology, surgery, and other departments. VISTA includes information from the abstract of the hospital discharge. It also records outpatient visits, including codes for the type of clinic visited, procedures and diagnoses.

Relative Value Units (RVUs) are assigned to each product based on an estimate of the relative costs of the resources needed to produce it. The department's cost per RVU is calculated, and multiplied by the RVUs assigned to the intermediate product to determine its cost. DSS assumes that the cost of producing an intermediate product is exactly proportional to the RVUs assigned to it. The Department Cost Manager (DCM) is the name of the DSS program that distributes overhead costs and determines the cost of each intermediate product.

RVUs play an important part in the cost allocation system. The same standard set of RVUs is provided to each facility when DSS is implemented. This starting set of RVU weights was developed in specific studies at different VA facilities that were thought by DSS managers to be the best available information. Facilities are encouraged to modify RVUs to reflect local factors. It is important that the RVUs accurately reflect the relative amount of resources used to produce each intermediate product. This same concern applies to the traditional method of cost-adjusted charges. The use of RVU is an advantage of the DSS system, for unlike charges, these are explicitly chosen to represent the relative cost of producing different patient care products. Another advantage of DSS is the use of six sets of RVUs, one for each of six types of cost.

The Clinical Cost Manager (CCM) is the program that aggregates data by patient encounter. It characterizes the number of intermediate products used, their cost and the total cost of that encounter. An inpatient encounter is a hospital stay. An outpatient encounter is defined as a clinic visit, with a residual category for all other services provided on a single day (e.g., lab tests conducted and prescriptions filled).

DSS National Data Extracts

A set of files has been created with the DSS estimate of the cost of every VA hospital stay, outpatient visit, and dispensed prescription. The National Data Extract (NDE) files report the cost of VA hospital stays and outpatient visits since October 1, 1998. The three core extracts include an inpatient discharge file, an inpatient treating specialty file, and outpatient files. The HERC guidebook on these DSS NDE files, and periodic technical reports analyzing their content, are available in the downloads section. The first three years' data have been purged from the Austin Automation Center. Data are now available about encounters since 2001.

HERC evaluated data in these datasets, and compared them to the HERC average cost estimates. Links to these technical reports are found in the downloads section, below.

DSS has created two department-level cost datasets, the Account Level Budget Cost Center (ABLCC) data set and the monthly Program Cost Report (MPCR). The ALBCC data set can be used by researchers to assign indirect costs when the direct costs of an intervention have been determined by micro-costing. The MPCR is used to estimate the costs of care for the VHA VERA budget model. HERC guidebooks describe the contents of these databases, how to access them, and provide examples of their use in research. These guides are also available in the downloads section.

VA researchers may also access DSS data via the VISN Support Services Center Web Site and the VA Financial Clinical Data Mart.  See the article in the HERC Bulletin Vol. 5, Issue 2, September 2005 and the VIREC Insights Vol. 3, numbers 2 and 3.

VA has also created extracts of dispensed prescriptions, completed laboratory tests, completed radiology tests, and results of 50 different laboratory tests. These extracts began October 1, 2001. Documentation on these extracts is available from the VA Information Resource Center (VIREC).

Obtaining Permission to Use DSS Data

DSS national extracts are stored in SAS format at the VA Austin Automation Center (AAC). Patient identifiers in these files have been encrypted as scrambled social security numbers. Employees of the Department of Veterans Affairs may obtain access to these files by completing a time-sharing request form (VA form 9957). The form must include the functional task codes for DSS files. The Chief of Service and other approving officials must sign this form. It is then submitted to the Automated Customer Registration System Point of Contact at your facility. VA employees can find the name of their ACRS Point of Contact by calling the AAC Help Desk at (512) 326-6780 and asking for the ACRS central office.

See the HERC VA Intranet web page on DSS to learn functional task codes and dataset names.

Obtaining Access to True Patient Identifiers

VA uses patient social security numbers to identify patients. VA researchers may access DSS files that use true social security numbers, at the medical center, VISN, or national level. A human subjects research review committee must approve the request. The researcher must provide a plan for maintaining the security of confidential information and disposing of it when the study is complete. The researcher must submit a signed time-sharing request form with the functional task code for true social security number files. After approval by the ACRS Point of Contact, the national VA research and development office and the VA privacy officer must also approve the request. VIREC maintains information on current procedures to request access to real social security numbers. See the response to FAQ 4 at the VIREC web site.

Access to Cost Data in DSS Production System

The standardized national data extracts should meet most researchers’ DSS data needs. They may not provide sufficient level of detail for certain types of research. For example, the extracts do not itemize the costs of all products used within a healthcare encounter. This level of detail requires direct use of the DSS production system. The production system keeps DSS data from each facility in a separate database at the VA Austin Automation Center. The simplest way to access these data is to ask the site or VISN staff to run a report using Toolkit or the Ad Hoc report utility.

It is very difficult to obtain permission to directly access the DSS production database. The applicant must submit a request to the DSS manager at the individual VISN or medical center. The applicant must also have an Austin Automation Center timesharing account with the functional task code giving permission to access production DSS data. This requires submission of a timesharing agreement. Production data always include unencrypted social security numbers. Requests thus require the same steps needed to access any database with the true social security numbers of VA patients.

Additional Resources

See the VA Intranet page on DSS to learn functional task codes and dataset names.

To ensure the protection of VA information, we have restricted access to certain files (denoted by the "lock" icon). Contact HERC to download these restricted files.

• Research Guide to Decision Support System National Cost Extracts 1998-2004

  Date: 2/8/2006 | Size: 325Kb

• Researchers' Guide to the DSS Monthly Program Cost Report (MPCR)

  Date: 1/20/2006 | Size: 349Kb

• VA economic data sets III: DSS NDEs

  Date: 7/20/2005 | Size: 179Kb

• VA Decision Support System (DSS)

  Date: 8/13/2003 | Size: 109Kb

• HERC or DSS Costs

  Date: 8/13/2003 | Size: 90Kb

• Estimating Indirect Costs with DSS Data

  Date: 8/13/2003 | Size: 163Kb

• DSS Production Data

  Date: 2/9/2001 | Size: 608Kb

• Comparison of DSS Encounter-Level National Data Extracts and the VA National Patient Care Database: FY2004

  Date: 11/26/2007 | Size: 364Kb

• Comparing Outpatient Cost Data in the DSS National Pharmacy Extract and the Pharmacy Benefits Management V3.0 Database

  Date: 11/15/2007 | Size: 144Kb

• A Comparison of Outpatient Costs from the FY 2001 HERC and DSS National Data Extract Datasets

  Date: 4/1/2007 | Size: 1375Kb

• A Comparison for Inpatient Costs from the HERC and DSS National Data Extract Datasets

  Date: 1/1/2004 | Size: 1.22Mb

• Reconciliation of DSS Encounter-Level National Data Extracts and the VA National Patient Care Database: FY2001-FY2002

  Date: 12/2/2003 | Size: 1.01Mb

• Reconciliation of DSS Encounter-Level National Data Extracts with the VA National Patient Care Database FY2001

  Date: 10/1/2002 | Size: 833Kb

• Austin DSS PROC CONTENTS File (Opat 2002)

  Date: 4/30/2004 | Size: 12Kb

• Austin DSS PROC CONTENTS File (Disch 2003)

  Date: 4/30/2004 | Size: 12Kb

• Austin DSS PROC CONTENTS File (Disch 2002)

  Date: 4/30/2004 | Size: 11Kb

• Austin DSS PROC CONTENTS File (Trt 2002)

  Date: 4/13/2004 | Size: 10Kb

• Austin DSS PROC CONTENTS File (Trt 2003)

  Date: 4/13/2004 | Size: 10Kb