Chapter 4 Healthcare Data Sets

What is Data CONTENT Standard?

Clear guidelines for the acceptable values for specified data fields.

What is the Minimum Data Set?

A comprehensive functional assessment that is required for all patients that are in a long term care facility.

Since the 1980s, the number and the length of inpatient hospitalizations have gone down dramatically at the same time healthcare procedures performed in ambulatory setting has gone up what are the reasons ?

-Technical improvements in diagnostic and therapeutic procedures and the development of short acting anesthetics. - Third party payers have extended coverage to include not procedures performed on an outpatient basis. - Medicares acute inpatient hospital prospective payment system limits reimbursement for inpatient care and as an alternative to more costly inpatient services.

Healthcare data sets have two purposes.

-The first is to identify the data elements that should be collected for each patient. - The second is to provide uniform definitions for commons terms. The use of uniform definitions ensures that data collected from a variety of healthcare settings will share a standard definition.

The data collected by the MDS are used to?

1. Develop care plans 2. Document placement at the appropriate level of care. 3. Assess resident safety and quality improvement activities in nursing homes.

How can information that is taken from the MDS be used by facilities?

1. It can be used to figure out how and where to spend their money. 2. It can be used to track conditions of patients and facilities.

Why has the number and length of inpatient hospitalizations gone down dramatically?

1. Technological improvements. 2. 3rd party payers have extended coverage to include procedures performed on an outpatient basis. 3. Medicare limits reimbursement for inpatient care in effect encouraging the use of ambulatory and out patient care.

What are the purposes of healthcare data sets?

1. To identify the data elements that should be collected for each patient. 2. To provide uniform definitions for common terms.

What is the data collected from OASIS used for?

1. Used to assess the patients ability to be discharged or transferred from home care services. 2. Used in measuring patient outcomes in order to assess the quality of home healthcare services. 3. Also used for a basis of reimbursement for provided services.

DEEDS recommends the collection of how many data elements in hospitals that offer emergency care services?

156 data elements

The MDS organizes data according to how many main categories

20

How many measures does HEDIS contain?

70 measures related to conditions such as heart disease, cancer, diabetes, asthma, chlamydia infection, osteoporosis, and rheumatoid arthritis.

What is the Resident Assessment Instrument?

A assessment instrument developed byMedicare and Medicaid to standardize the collection of skilled nursing facility patient data.

What is the SDO?

A government agency that is involved in the development of healthcare informatics standards on a national or international level.

What is the Hospital Discharge Abstract System?

A group of databases compiled from aggregate data on all patients discharged from a hospital.

Extensible Markup Language (XML)

A key tool for enabling data sharing.

What was the first thing that was done by the ARRA?

A permanent office was established in DC called the ONC (Office of the National Coordinator)

What is HEDIS?

A set of Standard performance measures designed to provide healthcare purchasers and consumers with the information needed to compare the performance of managed healthcare plans.

What is a Standard?

A well defined approach that supports a business process. It has been vetted, agreed upon and fits intended purpose.

ASC X12

Accredited Standards Committee Creates and develops standards for business transactions.

The contents of Data sets vary by their purpose. However, Data sets are not meant to limit the number of data elements that can be collected. Most healthcare organizations collect additional elements that have meaning for there specific _____________ and ____________

Administrative and Clinical operations

ADA

American Dental Association Develops Dental standards.

ANSI

American National Standards Institute It coordinates the development of voluntary standards in industries and healthcare

ASTM International

American Society for Testing Material Develops standards for security, record content and protocols for exchange of laboratory data.

Which of the following would be a core data set for a patients clinical summary?

CDA CCR* CCD QDS

Define CDA

Clinical Document Architecture. It is a HL7 XML based document markup standard for the electronic exchange model for clinical documents. Example, Discharge summaries and progress notes.

Structure and content standards

Common data elements and definitions to be included in an electronic patient record.

ASTM and HL7 combines their work to create the...

Continuity of Care Document

Define CCD

Continuity of Care Document. Provides an exchange between providers for the documentation of continuity of Care. Created by ASTM and HL7

Define CCR

Continuity of Care Record. Documentation of care delivery from one healthcare provider to another for referral, transfer or discharge.

The Resident Assessment Instrument is triggered by the at a collected by the:

Core measures DEEDS MDS* HEDIS

Which of the following is a set of performance measures used to compare the performance of managed healthcare plans?

DEEDS HEDIS* ORYX UHDDS

Which of the following is used to collect data about ambulatory care residents?

DRGs MDS ORYX UACDS*

Which of the falling is designed to collect a minimum set of data about inpatients?

DRGs NCHS UACDS UHDDS*

Define DEEDS.

Data Elements for Emergency Department Systems

What is aggregate data?

Data about a patient that can be extracted from individual health records.

Who publishes regulations for electronic transmissions?

Department of Health and Human Services

Metadata standards

Descriptive data that characterize other data to create a clearer understanding of meaning and a greater quality of information.

DICOM

Digital Imaging and Communication in medicine. Created to permit the interchange of biomedical image wave forms and related information. Example Xrays, MRIs, CT Scans.

What activities are made possible by data exchange standards?

Disease surveillance Outcomes research Decision making and policy development

CCR Continuity of Care Record

Documentation of care delivery from one healthcare experience to another.

What makes it possible for DEEDS to communicate and integrate with other information systems?

EDI Electronic Data Interchange

Vocabulary standards

Establishes common definitions for medical terms to encourage consistent descriptions of an individuals condition in the health record

What does data represent?

Facts

Which of the following was developed by the Joint Commission?

HEDIS MDS OASIS-C ORYX*

What 2 Committees were established as a result of the ARRA?

HIT Policy committee HIT Standards committee

HL7

Health Level 7 (The big one) Supports the exchange of clinical information

Define HEDIS

Healthcare Effectiveness Data and Information Set.

IEEE

Institute of Electrical and Electronic Engineers Develops standards for system interface transactions. Example Pacemakers, telemedicine devices and monitoring devices.

What is the purpose of uniform definitions?

It ensures that data collected from a variety of healthcare settings will share a standard definition.

What is the ORYX initiative?

It is a Joint Commission initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process.

What is the ONC?

It is a government oversite agency that provides leadership for the development and implementation of a interoperable health information technology infrastructure.

What is a Data Set?

It is a list of recommended data elements with uniform definitions that are relevant for a particular purpose.

What is OASIS?

It is a standardized data set designed to gather and report data about Medicare beneficiaries who are receiving services from a Medicare-certified home health agency. It is only for Medicare beneficiaries.

What is the purpose of the CCD?

It is an implementation guide for sharing Continuity of Care Record patient (CCR) summary data using the Clinical Document Architecture (CDA)

What is UPIN?

It is the Medicare Unique Physician Identification Number. It is a preferred method of identifying the attending physician and operation physicians. It is uniform across all data systems

Define UACDS

It is the Uniform Ambulatory Care Data Set.

Define UHDDS?

It is the Uniform Hospital Discharge Data Set.

What is a Data Element?

It is used to describe a single fact or measurement. An example would be Age, Weight, Height

What is aggregate data used for?

It is used to develop information about groups of patients.

Why is standardizing data elements and definitions a good idea?

It makes it possible to compare the data collected at different facilities.

What is the HIT Policy committee?

It provides policy FRAMEWORK for the development and adoption of a nationwide HIT infrastructure.

What is the HIT Standards committee?

It provides recommendations on standards, implementation and certification for electronic exchange

What is the Purpose of the Uniform hospital Discharge Data Set?

Its purpose is to list and define a set of common, uniform data elements collected from health records of every hospital inpatient and later abstracted from the health record and included in national databases.

What is the purpose of a Data Set?

Its purpose is to support uniform data collection and to support EHR development and information interchange.

Which of the following is used to gather data about Medicare beneficiaries receiving home care?

MDS NCHS OASIS-C* UHDDS

The ______________ is more extensive and includes more clinical data that either the UHDDS or the UACDS

MDS Minimum Data Set

CDA Clinical Document Architecture

Make documents machine readable so the they can be easily processed. It provides an exchange model for clinical documents: such as discharge summaries and progress notes.

What is the purpose of standardizing data elements?

Makes it possible to compare the data collected from different facilities.

What does information represent?

Meaning

HEDIS is an example of what kind of data collection tool?

Population based

Which of the following is used to collect data about long-term care residents?

NCHS MDS* UACDS UHDDS

Is the Uniform Ambulatory Care Data Set Mandatory?

No, but it is recommended. It has not been incorporated into federal regulations.

Define ONC.

Office of the National Coordinator

Define OASIS.

Outcomes and Assessment Information Set

Patients who receive ambulatory care services in hospital-based clinics and departments are referred to as

Outpatients

What is DATA EXCHANGE Standard?

Protocols that help ensure data transmitted from one system to another remains comparable

What are some of the benefits of Data Exchange Standards?

Provides a common language, Link data in a secure environment Share information

CCD Continuity of Care Document

Provides an exchange between providers that may be used for documentation of continuity of care. It was also recognized as part of the first set of interoperability standards.

Content Exchange Standard

Provides rules of how data are actually transmitted from one computer system to another.

Information

Refers to data that have been collected, combined, analyzed, interpreted, and/or converted into a form that can be used for a specific purpose.

Data

Represents basic facts and measurements

Data sets are formed for what activities?

Research, Clinical trials, Quality and Safety Improvement, Reimbursement Accreditation and Exchanging clinical Information

Some organizations collect data for specific administrative and clinical operations, what are they?

Research, Clinical trials, quality and safety improvement, reimbursement, and accreditation.

ASTM Standard E1384-02a

Standard that identifies the content and structure for EHRs

Define SDO.

Standards development organization

What is a TRANSACTION Standard?

Standards that support the seamless transmission of electronic data from one healthcare entity to another.

What is needed in order for data to be easily, accurately, and securely communicated and exchanged electronically?

Standards-----interoperability

What do Acute care hospitals use when reporting patient safety events?

The AHRQ Common Formats Version 1.1

What is ARRA?

The American Recovery and Reinvestment Act. Provides 19.2 Billion in spending for Health IT

This allows researchers to track inpatient history and patterns/outcomes of care over time.

The MEDPAR file

Data standardization became widely accepted under the leadership of what organizations?

The National Center for Health Statistics and The National Committee on Vital and Health Statistics.

Who sponsors HEDIS?

The National Committee for Quality Assurance (NCQA)

The Quality Data Model (QDM), formerly known as the Quality Data Set (QDS), is published by?

The National Quality Forum (NQF)

What is the Purpose of the UACDS?

To collect patient/client specific data elements on ambulatory care settings. Referred to as outpatients.

What is the goal of the UACDS?

To improve data comparison, and provide uniform definitions that help providers analyze patterns of care in ambulatory and outpatient settings.

What is the purpose of DEEDS?

To support the uniform collection of data in hospital based emergency departments and to reduce incompatibilities in emergency department records.

Which if the following best describes the DEEDS data set?

Uses data for home health outcomes research Collects data about hospital emergency encounter* Uses data for inpatient analysis Collects data for ambulatory care

Is the Uniform Hospital Discharge Data set Mandatory?

Yes

Is the RAI/MDS Mandatory?

Yes it is federally mandated.

Privacy and Security Standards

ensures that patient identifiable health information remains confidential and protected from unauthorized disclosure, alteration or destruction.

ASTM was instrumental in...

identifying a core data set off patients clinical summary with the publication in 2005 of ASTM E2369-05e2 Standard Specification for Continuity of Care Record (CCR)

The idea of data standardization became widely accepted during

the 1960s