Ch. 2 Information Integrity and Data Quality

Template-based data entry

A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. It assists the healthcare provider by providing direction in what is to be documented

Physician advisor (PA)

A hired staff by the healthcare facility to act as a liaison between the HIM or others and the patient's physician

Quantitative analysis

A review of the health record to determine its completeness and accuracy

Qualitative analysis

A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

Back-end speech recognition (BESR)

A speech recognition technology in which the physician dictates in the traditional manner and an editor listens to the audio and reviews the document created

Front-end speech recognition (FESR)

A speech recognition technology in which the physician or the dictator is the editor of the document that is dictated

Edit check

A standard feature in many applications' data entry and data collection software packages.

Data mapping

Allows for connections between two systems

Speech recognition

Also known as voice recognition, a technology that translates speech to text. The text must be edited, as speech recognition software may misunderstand words and therefore translate speech into text incorrectly

Secondary data source

Data derived from the primary data sources, such as the health record. secondary data sources include indices, registries, and other databases

Unstructured data fields

Data elements that allow for free text entry, which means that the user can type in any data that he or she chooses

Data accessibility

Data items can easily obtainable by authorized users

Data timeliness

Data should be recorded in an appropriate period of time after the event and should be available to the user when needed

Data accuracy

Data that are free of identifiable errors

Data currency

Ensures that data are up to date

Data consistency

Ensures that like data are the same on each document or computer screen

Data precision

Ensures that there is justification for the need to collect the data

Data relevancy

Extent to which healthcare-related data are useful for the purposes for which they were collected

Hot spot

Is a type of help message that is triggered when the cursor is placed on top of a data feild

Data quality measure

Mechanism to assign a quantitative figure to quality of care by comparison to a criterion. Quality measurements typically focus on structures or processes of care that have a demonstrated relationship to positive health outcomes

Data quality management

The business processes that ensure the integrity of an organization's data during collection, application, warehousing, and analysis

Data integrity

The extent to which healthcare data are complete, accurate, consistent, and timely

Data granularity

The level of detail at which the attributes and values of healthcare data are defined

Authorship

The origination or creation of recored information attributed to a specific individual or entity acting at a particular time

Data comprehensiveness

The patient's health record must be complete and all required data must be included

Data cleansing

The process of checking internal consistency and duplication as well as identifying outliners and missing data. In other words, it means looking for errors or problems with the data, such as duplicate patients

Data capture

The process of recording healthcare-related data in a health record system or clinical database

Version control

The process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth

Primary data source

comes directly from the original source such as a patient when talking about symptoms or the reason for coming to the healthcare facility

AHIMA data quality management model

displays the components of data quality management and the characteristics of data quality

Structured data fields

guide the users during the data entry process, limiting what a user can enter into the field

Direct data entry

includes a number of manual data entry methods such as keyboards, mouse, or other devices for entering data into the computer

Peer review

is a review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law

Natural language processing

is the technology that converts human language into data that can be translated then manipulated by computer systems

Data quality

reliability and effectiveness of data for its intended uses in operations, decision making, and planning.

Data definition

specific meaning of a healthcare-related data element