Chapter 6 Data Management C810

Data Modeling

The process of formalizing data requirements and the structure used to organize data

index

The secondary data sources that have been in existence the longest are the ________ that have been developed within facilities to meet their individual needs.

staging system

a classification system that describes the extent of cancer within a patient.

The National Cancer Institute sponsors the Physician Data Query (PDQ),

a da-tabase for cancer clinical trials.

AHIMA Data Quality Management Task Force

a framework for the design and management process and data qual-ity measures.

National Trauma Data Bank

a large database of aggregate data on trauma cases

An implant

a material or substance inserted in the body, such as breast implants, heart valves, and pacemakers.

the National Survey of Ambulatory Sur-gery

a representative sample of hospital-based and freestanding ambulatory sur-gery centers. Data include patient demographic characteristics, source of payment, information on anesthesia given, the diagnoses, and the surgical and nonsurgical procedures on patient visits to hospital-based and freestanding ambulatory sur-gery centers. The survey consists of a mailed sur-vey about the facility and abstracts of patient data.

attri-butes,

characteristics and are rep-resented as circles.

sec-ondary data source

Data taken from the primary health record and entered into registries and databases

Population-based cancer registries collect:

Demographic information about each case of cancer Information on the industrial or occupational history of the individuals with the cancers (to the extent such information is available from the same record) Administrative information, including date of diagnosis and source of information Pathological data characterizing the cancer including site, stage of neoplasm, incidence, and type of treatment

Medical Literature, Analysis, and Retrieval System Online (MEDLINE)

It includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, phar-macy, allied health, and veterinary medicine. HIM professionals use _____________ to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities

The DBMS data dictionary

developed in con-junction with development of a specific database. Modern DBMS's have built-in data dictionaries that go beyond data definitions and store information about tables and data relationships. These integrated data dictionaries are sometimes referred to as system catalogs, reflecting their technical nature.

the organi-zation-wide data dictionary

developed outside the framework of a specific database design pro-cess. This data dictionary serves to promote data quality through data consistency across the orga-nization. Individual data element definitions are agreed upon and defined. This leads to better qual-ity data and facilitates the detailed, technical data dictionaries that are integrated with the databases themselves. This ___________ document becomes a valuable resource for IS development.

Cancer registries

facility-based registry (located within a facility such as a hospital or clinic) or a population-based registry (gathering information from more than one facility within a geographic area such as a state or region).

Secondary data sources consist of

facility-specific indexes; registries, either facility or population based; and other healthcare databases.

Structured Query Language (SQL)

formal language used to retrieve information stored in relational databases. __________ defines a number of op-erations, or activities, which can be used to access data across tables based on a set of conditionals

The operation index

is arranged in numerical order by the patient's procedure code(s), usually using ICD or Current Procedural Terminology (CPT) codes. Information listed in the __________ index is generally the same as that listed in the disease index except that the surgeon may be listed in addition to, or instead of, the attending physician.

An index

is simply a report from a database that enables health records to be located by diagnosis, procedure, or physician.

National Practitioner Data Bank (NPDB)

mandated under the Health Care Quality Improve-ment Act of 1986 to provide a database of medical malpractice payments; adverse licensure actions including revocations, suspensions, reprimands, censures, probations, and surrenders of licenses for quality-of-care purposes only; and certain pro-fessional review actions (such as denial of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers

AHIMA has published data quality best practices

Access permissions: Define and enforce access to data. Data dictionary: A data dictionary exists and each data element is defined. The definitions are communicated to all staff. Standardized format: Use a standardized format to ensure consistency. State and federal laws: All laws, regulations, ac-creditation standards, and policies are followed. Data Integrity: Implement policies and pro-cedures throughout the patient encounter to ensure data integrity

The master patient index (MPI),

Also known as the master person index, contains pa-tient-identifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physician, and health record number.

Disease Index

Always includes the patient's health record num-ber as well as the diagnosis codes so that records can be retrieved by diagnosis. Because each patient is listed with the health record number, the _________________ is considered patient-identifiable data. The ________________also may include other information such as the attending physician's name or the date of discharge.

The National Nursing Home Survey

Data on the facility, current residents, and dis-charged residents. Information is gathered through an interview process.Both the current and discharged resi-dent interviews provide demographic informationon the resident as well as length of stay, diagno-ses, level of care received, activities of daily living (ADLs), and charges.

schema mapping

ERDs are converted into tables by a process called:

In the disease index

Each patient's diagnoses are converted from a verbal description to a numerical code, usu-ally using a coding system such as the Internation-al Classification of Diseases (ICD).

National Electronic Disease Surveil-lance System (NEDSS)

Evaluate trends in disease outbreaks. State and local public health departments also develop databases as needed to perform their duties of health surveillance, disease prevention, and research. An example of a state database is the infectious and notifiable disease database. The ___________which serves as a major part of the Public Health Information Network (PHIN). It provides a national surveil-lance system by connecting the CDC with local and state public health partners. This integrated system allows the CDC to monit

State Central

Formal reporting of cancer registry data is done through an annual report which goes to the ____________cancer registry and the Centers for Disease Control

National Health Care Survey (NHCS)

It con-sists of a number of databases, including: National Hospital Care Survey National Survey of Ambulatory Surgery National Nursing Home Survey National Home and Hospice Care Survey

Birth defects registries

Information on new-borns with birth defects. Provide information on the incidence of birth defects to study causes and prevention of birth defects, to monitor trends in birth defects to improve medical care for children with birth defects, and to target interventions for preventable birth defects such as folic acid to prevent neural tube defects.

accession registry

Lists patients in accession number order provides a way to monitor that all cases have been entered into the registry.

The National Library of Medicine produces two databases of special interest to the HIM profes-sional

MEDLINE and UMLS

Healthcare Integrity and Protection Data Bank (HIPDB)

Part of HIPAA mandated the collection of informa-tion on healthcare fraud and abuse because there was no central place to obtain this information.

Case finding for trauma diagnoses

Registrar may query the facil-ity's health information system looking for cases with codes in the trauma section of ICD-10-CM

Data banks

are developed, for example, for claims data sub-mitted on Medicare claims.

patient diagnosis codes

are entered into the facility health information system as part of the discharge processing of the patient health record.

Collaborative Stage Data Set

computer algorithms to describe how far a cancer has spread

Registries

contain more extensive data. _______ often require more extensive data from the patient record. Each _______ must define the cases that are to be included.

primary data source

contains information about a pa-tient that has been documented by the professionals who provided care or services to that patient.

Diabetes registries

data about patients with diabetes for the purpose of assistance in managing care as well as for research.

the National Home and Hospice Care Survey

data are collected on the home health or hospice agency as well as on its current and discharged patients. Data include referral and length of service, diagnoses, number of visits, patient charges, health status, reason for discharge, and types of services provided. Facility data are obtained through an interview with the administrator or designee. Patient information is obtained from the caregiver most familiar with the patient's care. The caregiv-er may use the patient's health record in answer-ing the interview questions.

entity

data objects rep-resented as rectangles. An _____ can be thought of as a class of objects that exist in the real world and have related properties. ________ can be a type of person, place, or thing.

Vital statistics

data on births, deaths, fetal deaths, marriages, and divorces.

Aggregate data

data on groups of people or patients without identifying any particular patient individually

two general types of data dictionaries

database management system data dictionary and the organizational-wide data dictionary

Trauma registries

databases on patients with severe traumatic injuries

relationships

describe associations between entities and are represented with diamonds

The population-based registry

ensure that all cases of cancer in the target area have been identified and reported to the central registry.

The law requires healthcare facilities to query the NPDB as part of the credentialing process

every two years thereafter

National Hospital Discharge Survey (NHDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS)

examination of care provided across treatment settings. Information on the utilization of healthcare provided in inpatient settings, emergen-cy departments, outpatient departments, and am-bulatory surgery centers are collected in one place.

unstructured, free text,

handwriting, e-mails, and transcrip-tion.

Data extracted and entered into disease databases

help researchers determine the effectiveness of alter-nate treatment methods and quickly demonstrate survival rates at different stages of disease.

acces-sion number

identifies the patient. The ___________ consists of the first digits of the year the patient was first seen at the facility, with the remaining digits as-signed sequentially throughout the year.

Aggregate clinical information

improves the diagnosis and treatment of cancer patients.

Most acute-care facilities maintain

indexes

Internal users of secondary data

individu-als located within the healthcare facility can identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmark-ing.

External users of patient data

individuals and institutions outside the facility like state data banks and federal agencies

NoSQL

it has a fast response time for large datasets. This is in part due to the fact that it does not distribute data across tables but holds data in one central place. Second, it scales out rather than up

The physician index

lists cases in order by physician name or physician identification number.It also includes the patient's health record number and may include other informa-tion, such as date of discharge. The ___________ in-dex enables users to retrieve information about a particular physician, including the number of cas-es seen during a particular time period.

Within the federal government, the organiza-tion most involved in health services research is the Agency for Healthcare Research and Qual-ity (AHRQ).

looks at issues related to the efficiency and effectiveness of the healthcare de-livery system, disease protocols, and guidelines for improved disease outcomes. ____________ also provides access to different types of data that are primarily used for quality and utilization manage-ment purposes.

The Medicare Provider Analysis and Review (MEDPAR) file

made up of acute-care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. The ____________ file is frequently used for research on topics such as charges for particular types of care and analysis by DRG. The limitation of the ___________ data for research purposes is that it only contains data about Medicare patients.

AHIMA defines documentation as

methods and activities of collecting, coding, ordering, storing, and retrieving information to fulfill future tasks

Case finding

methods used to identify the patients who have been seen and treated in the fa-cility for the particular disease or condition of inter-est to the registry.

Relational databases

most widely used in numerous industries, including healthcare. This model consists of a database with a set of formally described tables, related (linked) to each other by a shared reference. It is widely used because it offers a simple, yet powerful view of stored information. Devel-opers can easily understand how information is organized and users can create their own interac-tive queries. It is flexible enough that databases can be simple or complex, and yet each part has an easy to understand representation.

Healthcare organizations

must establish data quality standards specific to the intended use of the data or resulting information.

The Abbreviated Injury Scale (AIS)

nature of the injury and the severity (threat to life) by body system. It may be assigned manually by the registrar or generated as part of the database from data entered by the registrar.

diabetes registries

often maintained by physi-cian offices and clinics because they are the main location for diabetes care.

Registries are an example of

patient-identifiable data

Case definition

process of deciding what cases should be entered in the registry.

Cancer staging

process of determining the size and extent of spread of the tumor through-out the body.

Transplant registries

provide a database of po-tential donors for transplants using live donors, such as bone marrow transplants. Posttransplant information also is kept on organ recipients and donors.

diagnosis index

provide a list of diagnoses in numerical order and allow select-ing those with the appropriate diagnosis code

In an acute care setting, the disease index

provide diagnosis code number order for patients dis-charged from the facility during a particular time period.

Cancer data from facility-based registries

provide information for the improved under-standing of cancer, including its causes and meth-ods of diagnosis and treatment. The data collected also may provide comparisons in survival rates and quality of life for patients with different treat-ments and at different stages of cancer at the time of diagnosis. In population-based registries, em-phasis is on identifying trends and changes in the incidence (new cases) of cancer within the area covered by the registry.

Secondary data sources

provide information that is not easily available by looking at indi-vidual health records.

National Center for Health Statistics (NCHS)

provides a database of statistical health information to guide public health action and health policy making. Their website provides information on population health status and trends in health status and care delivery

The Unified Medical Language System (UMLS)

provides a way to integrate biomedical concepts from a variety of sources to show their rela-tionships. This process allows links to be made between different information systems for pur-poses such as the electronic health record. __________ is of particular interest to the HIM professional because medical classifications such as ICD-10-CM, CPT, and the Healthcare Common Proce-dure Coding System (HCPCS) are among the items included.

Immunization registries

record the number of infants and chil-dren who receive proper immunizations at the proper intervals.

Health services research

research concerning healthcare delivery systems, including organization and delivery and care effectiveness and efficiency.

A data dictionary

set of descriptions of data items in a data model for reference for systems users.

The Injury Severity Score (ISS)

severity measurement cal-culated from the AIS scores for the three most severe injuries of the patient

Examples of aggregate data

statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis-related group (DRG).

All cancer registry data is formally reported to the state central registry and

the Centers for Disease Control

abstracting,

the process of reviewing the patient health record and entering the required data ele-ments into the database.

Case finding can be accomplished

through the discharge process in the HIM department or use the facility-specific dis-ease indexes or the health information system to identify patients with diagnoses of cancer.

In nonacute settings, the disease in-dex is generated

to reflect patients current-ly receiving services in the facility.

Database management systems (DBMS)

tools used to store, analyze, modify, and access data.

Implant registries

tracking the perfor-mance of implants, including complications, deaths, and defects resulting from implants, as well as longevity.

the National Health Interview Survey

used to monitor the health status of the population of the United States, and the National Immunization Survey, which collects data on the immunization status of children between the ages of 19 months and 35 months living in the United States.

Health-care Cost and Utilization Project (HCUP) which

uses data collected at the state level from either claims data from the UB-04 or discharge-abstracted data, including UHDDS items reported by indi-vidual hospitals and, in some cases, by freestanding ambulatory care centers.

The case definition for the trauma registry

varies from registry to registry.

entity relationship diagram (ERD)

visually rep-resents and defines groupings of data and their relationships to each other

A traumatic injury

wound or another injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall.