C810- Data & Information Governance Study Guide
Semantic Interoperability
The degree to which there is mutual understanding of the meaning of data exchanged between information systems. (use of HL7 or SNOMED-CT)
Data Governance (DG)
The overall administration, that defines procedures and plans, that assures the availability, integrity, security and usability of the structured and unstructured data available to an organization and is concerned with governing the input (data)
Data Governance (DG) Steering Committee
This group serves as the coordinating body for the DG program. It develops the goals of the DG program, identifies and sequences project and task priorities, coordinates the data steward committees, monitors DG program outcomes, recommends policy and standards, and reports the status of the DG program to the executive data governance council.
(Name the IG Principle) Communication, informing, sharing information, decreasing miscommunication, improving communication.
Transparency
standardized data set for the ambulatory setting. "The UACDS collects data specific to ambulatory care settings with an intent to improve data comparison across different settings of healthcare." It includes elements such as reasons for the encounter, living arrangements, and marital status. The UACDS is not required, rather it is recommended.
Uniform Ambulatory Care Data Set (UACDS)
"collects uniform data elements from health records of every hospital inpatient". Data such as principal diagnosis, principal procedure, and other significant procedures are included. There are specific criteria for the collection of each data element. UHDDS is the standard for collecting Medicare and Medicaid data. UHDDS definitions are a component of diagnostic related groups (DRGs), and are required to accurately calculate DRG payment
Uniform Hospital Discharge Data Set (UHDDS)
Example: Freestyle Writing
Unstructured Data
Information Governance (IG)
Uses policies, procedures, and multidisciplinary arrangements to manage and optimize an organization's information for its immediate and future needs including regulatory, legal, risk, environmental, and operational requirements, and is concerned with governing the output (information) of an information system (IS).
Subject Matter Stewards
_________________ within business areas who have a high level of accountability for the management of the data, but not necessarily the day-to-day hands-on responsibilities.
Case Management
a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
Charge Description Master (CDM)
an electronic file that represents a master list of all services, supplies, devices, and medications charged for inpatient or outpatient services
Data Steward
an individual appointed with responsibility and accountability for data, usually in a specific domain. Develops data definitions and models.
DG Council
authorized by the DG steering committee, is usually responsible for establishing DG policy and standards and monitoring their implementation.
Data Definition Stewards (Domain Coordinators)
function in a business, as opposed to a technical role; major responsibilities include identifying the specific data needed to operate business processes, recording business definitions and metadata, identifying and enforcing quality standards, communicating data issue concerns, and communicating new or changed business requirements.
Data Sets
identifies the data elements to be collected for each patient and provides uniform definitions for common terms.
Data Standardization
process of making sure the data conforms to predefined formatting standards. Classifications are used to aggregate data for functions like data analysis & reimbursement.
Charge Capture
process of recording billable services
Stakeholder Analysis
process that identifies and analyzes attitudes or opinions of stakeholders. How the analysis is designed depends on the mission, scope and specific projects undertaken by the DG program.
Functional Interoperability
refers to sending messages between computers with a shared understanding of the structure and format of the message
Data Governance
refers to the overall management of the availability, usability, integrity, and security of company data
Basic Interoperability
relates to the ability to successfully transmit and receive data from one computer to another
Middle process (of the Healthcare Revenue Cycle)
represents the intersection of clinical practice, documentation, and coding with charge capture to bill for services provided. Also includes, Chargemaster, Case Management, Clinical Documentation and Coding
Rules of Engagement
specify the way that policy makers, data owners, data stewards, and other stakeholders interact with each other.
Clinical Documentation Integrity (CDI)
the process of reviewing medical information to verify that documentation is clinical specific, is appropriate, and supports the medical codes assigned. (aka Clinical Documentation Improvement)
Revenue Cycle
the sequence of processes to progress a patient account from creation to closing.
Revenue Cycle Management
the strategy implemented to direct administrative and clinical functions associated with capturing and monitoring, and collecting of patient service revenue.
Data Stakeholders
those who have an interest or stake in organizational data.
Information Governance (IG) Principles
1. Accountability 2. Transparency 3. Integrity 4. Protection 5. Compliance 6. Availability 7. Retention 8. Disposition
Essential Rules of Engagement in the DGI Framework
1. create a mission statement 2. develop DG program goals 3. establish DG metrics and success measures 4. determine DG funding strategy 5. develop data rules and definitions 6. assign decision rights 7. assign accountability 8. establish control to prevent and mitigate risks
Utilization Management
A planned, systemic review of patients receiving healthcare services against criteria for appropriateness of services being provided as well as admission, continued stay, and discharge planning.
Principle of Integrity
A principle generated by, managed for, or provided to the organization as a reasonable and suitable guarantee of authenticity and reliability
(Name the IG Principle) Top Leadership (CFO, CIO, CEO, Steering Committee) taking action.
Accountability
Principle of Protection
An IG program must ensure that the appropriate levels of protection from breach, corruption, and loss are provided for information that is private, confidential, secret, classified, essential to business continuity, or otherwise requires protection.
Principle of Compliance
An IG program shall be constructed to comply with applicable laws, regulations, standards, and organizational policies.
Principle of Accountability
An accountable member of senior leadership shall oversee the IG program and delegate responsibility for information management to appropriate individuals.
Principle of Availability
An organization shall maintain information in a manner that ensures timely, accurate, and efficient retrieval.
Principle of Retention
An organization shall maintain its information for an appropriate time, taking into account its legal, regulatory, fiscal, operational, risk, and historical requirements.
Principle of Disposition
An organization shall provide secure and appropriate disposition for information no longer required to be maintained by applicable laws and the organization's policies .
Principle of Transparency
An organization's processes and activities relating to IG shall be documented in an open and verifiable manner.
Data Usage Stewards
Are data users who access and use data for its intended purpose; access information about the data (metadata); ensure the quality, completeness, and accuracy of data usage; and communicate data issue concerns and new or changed business requirements.
(Name the IG Principle) Medical record/EHR is accessible when needed
Availability
DG Program is headed by the:
Chief Data Steward, Chief Data Officer, or other Senior Data Management Professional
(Name the IG Principle) Taking action to meet a requirement, law, mandate, regulation, policy.
Compliance
(1) Rules and Rules of Engagement (2) People and Organizational Bodies (3) DG processes
DG Framework
a data set used to support the uniform collection of data for hospital-based emergency rooms and to reduce incompatibilities in emergency department records. Because DEEDS also incorporates national standards for electronic data exchange, it can be integrated and shared via electronic health records.
Data Elements for Emergency Department Systems (DEEDS)
Data Governance Includes
Data Models Metadata Management Master Data Management Content Management Data Security Management Data Quality Management
Cross-Functional
Data stewards may be organized in program teams focused on specific initiatives that support the organization's DG mission and scope. Usually these teams are , meaning they are composed of individuals_________________, that represent different business units, including IT.
Unstructured Data
Data that (1) is not defined and does not follow a specified format (2) can not be managed but is usually stored as an object in its original, raw format and only manipulated when needed. Example: data contained in text documents (Qualitative)
Structured Data
Data that (1) is organized and easily retrievable and interpreted by traditional databases and data models. (2) can be categorized, defined and stored in a consistent structure. (i.e. DBMS) Example: data store in databases (Quantitative)
DIKW Hierarchy
Defines the transition of data to information to knowledge to wisdom. Hierarchy is dependent on the previous level. (Ex: no information exists w/o data) (Data> Information> Knowledge> Wisdom)
Data Steward Tasks
Development of Data Definitions and Data Models Resolution of Data Issues Data Quality Monitoring Testing of Data Security Procedures
(Name the IG Principle) Location; Where is the record going to be destroyed? Is the record going to storage?
Disposition
· Degree of compliance with DG security policies · Degree of master data accuracy over time · Degree of compliance with data model development standards · Length of time in which data issues are remediated
Examples of KPIs of a DG Program
a set of standard performance measures "designed to collect administrative, claims, and health record review data". "Included are data related to patient outcomes and data about the treatment processes important in the evaluation and success of various treatment plans". Health plans often publicly release HEDIS data to show positive effects of certain interventions on their clients.
Healthcare Effectiveness Data and Information Set (HEDIS)
Data Production Stewards (Operational Stewards)
In a business or technical role and are responsible for inserting, updating, and deleting business and technical data in IT systems; validating data that enters and exits business processes; coding and editing data quality standards such as format and con-tent; and communicating data issue concerns and new or changed business requirements.
(Name the IG Principle) Accurate data, complete, authenticate data is what its supposed to be.
Integrity
Data Governance Office (DGO)
Led by an individual with the title of chief data officer (CDO) or data governance program director. Responsibilities of the DGO are: (1) providing centralized communication and archive for data governance (DG) initiatives (2) working with stakeholders (3) coordinating DG initiatives (4) facilitating and coordination data steward committees, task forces, and meetings (5) supporting the data governance council (6) collecting and analyzing DG metrics.
Syntactic Interoperability
Message format standards identify how the data should be formatted or structured to allow the exchange. Interface software must be employed for compatibility to enable the exchange
Example: Timestamp
Metadata
for long term care settings. This is a federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents that must be completed for every resident at the time of admission and during reassessment periods; used to develop care plans and document placement at the appropriate care level. The MDS is also used to collect data when classifying Medicare residents into Resource Utilization Groups (RUGS). RUGS categories include services that require special care to long term setting residents, such as certain medical or cognitive issues.
Minimum Data Set (MDS)
- An initiative that integrates outcomes data and other performance measurement data into the Joint Commission Accreditation process. It promotes a comprehensive, continuous, data-driven accreditation process for healthcare facilities. It uses nationally standardized performance measures to improve the safety and quality of healthcare
Outcome Research Yields Excellence (ORYX)
a standardized data set designed to provide the necessary data items needed to measure both outcomes and patient risk factors of Medicare beneficiaries receiving skilled services from a Medicare-certified home health agency. The core data item set is for the collection on all adult home health patients whose skilled care is reimbursed by Medicare and Medicaid (excluding pre- or postnatal care)". Review of OASIS data is used to help determine when the patient should be discharged from home health, or if they need to be transferred to other services.
Outcomes and Assessment Information Set (OASIS)
(Name the IG Principle) Data security, preventing violations or breaches, correcting violations or breaches.
Protection
Information Governance Includes
Release of Information Retention and Disposal Policies Documentation Requirements Legal Hold Regulatory Compliance Records Management Ethical Use of Information Intellectual Property Ownership
Red Flag Rules
Requires organizations to implement a written identity theft prevention program designed to detect "red flags". Four Basic Identity Theft Prevention Elements. 1. Include reasonable policies and procedures to identify the red flags of identity theft 2. Design the program to be able to detect red flags that have been identified in step one. 3. Detail appropriate actions when red flags are detected 4. Detail how to keep the plan current and to detect new and emerging threats
(Name the IG Principle) Time; (When & How long the record is kept)
Retention
Polices Standards Controls Accountabilities
Rules Examples-(set of principles and regulations)
Example: Drop Down Menu
Structured Data
Key Performance Indicators (KPIs)
Success Measures developed to assess the effectiveness of the DG program.
Governance
The authority that ensures policies, standards, and accountabilities are in place and enforced for data management.
Interoperability
The capability of different information systems and software applications to communicate and exchange data. Types: Basic, Functional, Semantic, Syntactic
