Chapter 9 Managing Health Data

computer output to laser disc (COLD)

Forms or reports generated from computer output transferred for storage on laser disc.

incidence

Number of occurrences of a particular event, disease, or diagnosis or the number of new cases of a disease.

incidence . .

Number of occurrences of a particular event, disease, or diagnosis or the number of new cases of a disease.

Health Information Technology for Economic and Clinical Health (HITECH)

Act A subset of the American Recovery and Reinvestment Act (2009) legislation providing federal funding and mandates for the use of technology in health care.

Acute care facility

retain records 10 years for adults Age of majority + 10 years for minors (or statute of limitations)

information governance

strategic development of policies and procedures regarding the use of the organization's data.

coding

the systematic assignment of numbers or letters to items to classify and organize them

redundant arrays of independent disks (RAIDs)

"Stacked" hard drives that split up and duplicate data to enable larger capacities and faster access.

Medicare Severity Diagnosis-Related Group (MS-DRG)

A collection of health care descriptions organized into statistically similar categories.

field

A collection or series of related characters. A field may contain a word, a group of words, a number, or a code, for example.

cloud computing

A computing architecture in which the resources, software, and application data are Internet based rather than existing on a local system.

aggregate data

A group of like data elements compiled to provide information about the group.

acute care facility

A health care facility in which patients have an average LOS less than 30 days and that has an emergency department, operating suite, and clinical departments to handle a broad range of diagnoses and treatments.

data dictionary

A list of details that describe each field in a database.

scanner

A machine, much like a copier, used to turn paper-based records into digital images for a computerized health record.

enterprise master patient index (EMPI)

A master patient index shared across a multihospital system, such as an HIE

quality assurance (QA)

A method for reviewing health care functions to determine their compliance with predetermined standards that requires action to correct noncompliance and then follow-up review to ascertain whether the correction was effective.

patient account number

A numeric identifier assigned to a specific encounter or health care service received by a patient; a new number will be assigned to each encounter, but the patient will retain the same MRN.

personal health record

A patient's own copy of health information documenting the patient's health care history and providing information on continuing patient care.

Healthcare Effectiveness Data and Information Set (HEDIS)

A performance measure data set published by health insurance companies that employers use to establish health care contracts on behalf of their employees.

outguide

A physical file guide used to identify another location of a file in the paper-based health record system.

American Health Information Management Association (AHIMA)

A professional organization supporting the health care industry by promoting high-quality information standards through a variety of activities, including but not limited to accreditation of schools, continuing education, professional development and educational publications,

electronic health record (EHR)

A secure real-time point-of-care patient-centric information resource for clinicians allowing access of patient information when and where needed and incorporating evidence-based decision support.

meaningful use

A set of measures to gauge the level of HIT used by a provider and required, in certain stages, in order to receive financial incentives from CMS.

terminal-digit filing system

A system in which the patient's MRN is separated into sets for filing, and the first set of numbers is called tertiary, the second set of numbers is called secondary, and the third set of numbers is called primary.

managed care

A type of insurer (payer) focused on reducing health care costs, controlling expensive care, and improving the quality of patient care provided.

medical record number (MRN)

A unique number assigned to each patient in a health care system; this code will be used for the rest of the patient's encounters with that specific health system.

revenue cycle management (RCM)

All the activities that connect the services being rendered to a patient with the provider's reimbursement for those services.

American Recovery and Reinvestment Act (ARRA)

Also called the stimulus bill, 2009 federal legislation providing many stimulus opportunities in different areas. The portion of the law that finds and sets mandates for HIT is called the HITECH (Health Information Technology for Economic and Clinical Health) Act.

AOA

American Osteopathic Association

The Joint Commission (TJC)

An organization that accredits and sets standards for acute care facilities, ambulatory care networks, long-term care facilities, and rehabilitation facilities, as well as certain specialty facilities, such as hospice and home care. Facilities maintaining TJC accreditation receive deemed status from the CMS.

statistics

Analysis, interpretation, and presentation of information in numeric or pictorial format derived from the numbers

certification

Approval by an outside agency, such as the federal or state government, indicating that the health care facility has met a set of predetermined standards.

Support and collection of reimbursement

Documentation of health care is used to support and collect reimbursement for services rendered to patients.

CARF

Commission on Accreditation of Rehabilitation Facilities

electronic document management system (EDMS)

Computer software and hardware, typically scanners, that allow health record

patient portal secure

Electronic access, for the patient, to one or more components of a patient's record.

operative report

he surgeon's formal report of surgical procedure( s) performed. Often dictated and transcribed into a formal report.

Administration

Health information is used to make decisions regarding the delivery of health care services.

Licensing, accreditation, and certifications

Health information must be maintained as a requirement of licensure. Likewise, it supports compliance with certification requirements and accreditation standards.

history and physical (H& P)

Health record documentation comprising the patient's history and physical examination; a formal, dictated copy must be included in the patient's health care record within 24 hours of admission for inpatient facilities.

permanently

How long do you retain birth, death, surgical procedure records

permanently

How long do you retain emergency room data?

30 years

How long do you retain employee health records?

Age of majority +10 years

How long do you retain fetal monitor strips?

5 years

How long do you retain radiographs?

protected health information (PHI)

Individually identifiable health information that is transmitted or maintained in any form or medium by covered entities or their business associates.

permanetly

how long do you retain master patient index (MPI)?

NIAHO

National Integrated Accreditation for Healthcare Organizations

NUBC

National Uniform Billing Committee

Health Insurance Portability and Accountability Act (HIPAA)

Public Law 104-191, federal legislation passed in 1996 that outlines the guidelines of managing patient information in terms of privacy, security, and confidentiality. The legislation also outlines penalties for noncompliance.

prevalence

Rate of incidence of an occurrence, disease, or diagnosis or the number of existing cases.

10 years

how long do you retain the diseases index

document imaging

Scanning or faxing of printed papers into a computer system or optical disc system.

TJC

The Joint Commission

deemed status

The Medicare provision that an approved accreditation is sufficient to satisfy the compliance audit element of the COP.

Department of Human and Health Services (DHHS)

The U.S. agency with regulatory oversight of American health care, which also provides health services to certain populations through several operating divisions.

claim

The application to an insurance company for reimbursement of services rendered.

case mix index

The arithmetic average (mean) of the relative weights of all health care cases in a given period.

continuity of care

The broad range of health care services required by a patient during an illness or for an entire lifetime. May also refer to the continuity of care provided by a health care organization. Also called continuum of care.

abstracting

The recap of selected fields from a health record to create an informative summary. Also refers to the activity of identifying such fields and entering them into a computer system.

data governance

The development, implementation, and monitoring of policies and procedures that ensure the quality of data as entered and the integrity of that data as stored and used across multiple applications and systems within the organization.

mortality rate

The frequency of death

Improvement in patient care .

The health care facility uses the documentation in the health record to determine patient care.

granularity

The level of detail with which data are collected, recorded, or calculated.

Uniform Hospital Discharge Data Set (UHDDS)

The mandated data set for hospital inpatients.

retrospective review

The part of the utilization review process that concentrates on a review of clinical information following patient discharge

utilization review (UR)

The process of evaluating medical interventions against established criteria, on the basis of the patient's known or tentative diagnosis. Evaluation may take place before, during, or after the episode of care for different purposes.

morbidity rate

The rate of disease that can complicate a condition for which the patient is seeking health care services or the prevalence of a particular disease within a population

analysis

The review of a record to evaluate its completeness, accuracy, or compliance with predetermined standards or other criteria.

health information technology (HIT)

The specialty that focuses on the day-to-day activities of HIM that supports the collection, storage, retrieval, and reporting of health information.

operative report

The surgeon's formal report of surgical procedure( s) performed. Often dictated and transcribed into a formal report.

release of information (ROI)

The term used to describe the HIM department function that provides disclosure of patient health information.

litigation

The term used to indicate that a matter must be settled by the court and the process of engaging in legal proceedings.

Conditions of Participation (COP).

The terms under which a facility is eligible to receive reimbursement from Medicare. certification Approval by an outside agency, such as the federal or state government, indicating that the health care facility has met a set of predetermined standards.

storage area network (SAN)

The use of RAIDs and other storage technologies over a network.

accreditation .

Voluntary compliance with a set of standards developed by an independent agent, who periodically performs audits to ensure compliance

Centers for Disease Control and Prevention (CDC)

federal agency that collects health information to provide research for the improvement of public health.

DD

date dictated

DT

date transcribed