HI - Chap 9 - MXW
What is the definition of "stage of Neoplasm"?
Stage of Neoplasm - A classification of malignancies (cancers) according to the anatomic extent of the tumor, such as primary neoplasm, regional lymph nodes, and metastases
What are Cancer Registries?
The most famous of the registry. Can either be facility-based or population-based. They collect information about the demographics of each case of cancer. It is been recognized that the information in it is needed to improve the diagnosis and treatment cancer. Type and site of the cancer, Diagnostic and Treatment methodologies; Stage at the time of diagnosis. Uses Collaborative Stage data Set; Annual Basis
What is a transplant Registries?
Transplant Registries (494) - Some organ transplant registries maintain databases of patient who need organs. Provide database of potential donors for transplants using live donors, such as bone marrow transplants. Post-transplant information also is kept on organ recipients and donors. Data Collected: Patient's diagnosis; Patient's status codes regarding medical urgency; Patient's functional status; Is patient on life support: Histocompatibility
What are Vital Statistics?
Vital Statistics - Data related to births, deaths, marriages, and fetal deaths.
What is the abbreviated Injury Scale (AIS)
Abbreviated Injury Scale (AIS) - A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system.
Who approves of the cancer-related programs, including the cancer registries and strauma centers?
American College of surgeons (ACS) Commission on Cancer (488) -The organization that approves cancer-related programs, including cancer registries and trauma centers. Standards are published in the Cancer Program Standards. When the ACS surveys the cancer program, part of the survey process is a review of cancer registry activities. 63.00
What is an external User?
External Users - Individuals and institutions outside the facility (Example are state data banks and federal agencies)
Four major purposes for collecting secondary data?
(1) Quality, performance, and patient safety ; (2) Research. Data taken from health records and entered into disease-oriented databases can help researches determine the effectiveness of alternate treatment methods ; (3) Population health. ; (4) Administration (Example - Credentialing physicians)
What is a trauma Registry
- A wound or other injury caused by an external physical force such as automobile accident, a shooting, a stabbing, or a fall. Trauma registries may be facility bases or may include data for regional or state. Level 1 trauma centers must have a Trauma Registry. The data elements collected in the abstracting process vary but may included Abbreviated Injury Scale; Injury Severity score: Patient's course in hospital; Diagnosis and procedure codes
What are several factors must be addressed when assessing data quality?
(1) Accuracy of the data. ; (2) Consistency of the Data; (3) Comprehensiveness of the data; (4) Timeliness of the Data; and (5) Data Security
What is an Implant Registries?
- An implant is a material or substance inserted into the body, such as breast implants, heart valves, and pacemakers. Purpose of tracking the performance of implants, including complications, deaths, and defects resulting from implants as well as implant longevity. The Safe Medical Devices Act of 1990 was passed and then amended thought he medical Devices Amendments of 1992. These acts required a sample of facilities to report deaths and severe complications thought to be due to a device to the manufacturer and the Food and Drug Administration. Includes Name and address of the device manufacturer; Device brand name and common name; Product model, catalog, serial, and lot number; Brief description of the event reported to the manufacture and/or the FDA
What are facility-based registries?
Facility-based registries - A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic
What is the main difference between a registry and a index?
A Registry cotains more data than a index.
What is a Accession Number?
Accession Number - A number assigned when a case is first entered in the registry, an accession number is assigned. This number consists of the first digits of the year the patient was first seen at the facility, and the remaining digit are assigned sequentially throughout the year.
What is an Accession Registry?
Accession Registry - Listing of all numbers listed in the registry. All of the cases that are assigned and accession number are kept manually or provided as a report by the database software. This listing of patients in accession number order provides a way to ensure that all cases have been entered into the registry.
What are Activites of Daily Living?
Activities of Daily Living - The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating
What is AHRQ?
Agency for Healthcare Research and quality (AHRQ) - Look at the efficiency and effectiveness of healthcare systems. The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services.
What is aggregate data?
Aggregate data - Data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed. Most secondary data is considered aggregate data.
What is Consistency of the Data?
Also referred to as data reliability. Example, all patients in a trauma registry with the same level, severity, and site of injury should have the same score on the Abbreviated Injury Scale.
What are the Case Findings?
Case Findings - How we are going locate those cases. A method of identifying patients who have been seen and/or treated in a healthcare facility for the particular disease or condition of interest to the registry
What is a case definition?
Case definition - A method of determining criteria for cases that should be included in a registry. Define what types of case are going to be included in the registries
What are Clinical Trials?
Clinical Trial - A controlled research study involving human subjects that is designed to evaluate prospectively the safety and effectiveness of new drugs, tests, devices, or interventions
What is definition of Collaborative stage data?
Collaborative stage Data - A new standardized neoplasm staging system developed by the American Joint Commission on Cancer.
What is the Birth Defects Registries?
Collects information on newborns with birth defects. They 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. A variety of information: Birth weight; Codes for diagnoses; Mother's use of alcohol, tobacco, or illicit drugs; Father's use of drugs and alcohol; Family history of birth defects
What is a Diabetes Registries?
Diabetes registries include cases of patients with diabetes for the purpose of assistance in managing care as well as for research. Diabetes registry can keep up with whether the patient has been seen by a physician in a effort to prevent complications. Type of diabetes mellitus: type 1 and type 2 diabets: Registries sometimes limit there cases by type of diabetes and age. Other information: Diagnostic codes; Billing data; Medication lists; Physician identification; Health plans. May also include laboratory values. Facility-based; Population-based and Follow-up is aimed primarily at ensuring that the diabetic is seen by physician to prevent complications.
What is a Disease Index?
Disease Index - A listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each patient's diagnoses code is converted from a verbal description to a numerical code. An index includes the patient's health record number as well as the diagnosis codes so that records can be retrieved by diagnosis.
What is a Disease Registries?
Disease registries - They contain more extensive data. Can usually be produced using data from the facility's existing database. Each registry must define the cases that are to be included in it. A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery. Sole purpose of some registries is to collect data from health records and to make them available for users.
What is Data Security?
Efforts to control access to health information. The process of keeping data safe from unauthorized alteration or destruction
Interrater Reliability
Have more than one person to do the same task and then check to see if there are any discrepancies.
What is a Healthcare database?
Healthcare Databases - May be developed for a variety of purposes. Example the federal government has developed a variety of databases to enable it to carry out surveillance, improvement, and prevention duties. They also may use this data to do research or work with other researchers on issues related to reimbursement and health status.
What is the Healthcare Integrity and Protective Data Bank?
Healthcare Integrity and Protection Data Bank - A database maintained by the federal government to provide information on fraud-and-abuse findings against U.S. healthcare providers. This database collects any information on any type of provider that commits healthcare fraud or abuse. Clearing house for individuals that do wrong.
What is Timeliness of the Data?
Healthcare data should be up-to-date. Data must also be available within a time frame helpful to the user. Factors that influence decisions may change over time, so it is important that data is up-to-date.
What is Histocompatibility mean?
Histocompatibility - Compatibility of donor and recipient tissues. The immunologic similarity between an organ donor and a transplant recipient
A Immunization Registries?
Immunization Registries - Have the purpose of increasing the number of infants and children who receive the required immunizations at the proper intervals. Helps by maintaining a central source of information for a particular child's immunization history, even when the child has received immunizations from a variety of providers. Central location for immunization data also relieves parents of the responsibility of maintaining immunization records for their children. Data element: Patients name, date, sex, race, ethnicity, birth order, birth state/county; Mothers name; vaccine type, manufacturer, date, and lot number.
What is a incidence?
Incidence - The number of new cases of a specific disease
What are indexes?
Indexes - An organized (usually alphabetical) list of specific data that services to guide, indicate, or otherwise facilitate reference to the data. Road map pointing to those locations of health records that meet the criteria.
What is the Injury Severity Score?
Injury Severity Score (ISS) - An overall severity measurement maintained in the trauma registry and calculated from the abbreviated injury scores for the three most severe injuries of each patient
What are Internal Users ?
Internal users of secondary data are individuals located within the healthcare facility (Internal users include medical staff and administrative and management staff)
What is an MPI?
Master Population/Patient Index (MPI) - Sometimes called master person index, contains patient-identifiable data such as name, address, date of birth, dates of hospitalization or encounters, name of attending physician and health record number
What is MEDLINE?
Medical Literature, Analysis and Retrieval System Online (MEDLINE) - Best known database from the NLM. It includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine. Used to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities.
What is MEDPAR?
Medicare Provider Analysis and Review (MEDPAR) - A data base that is made up of acute care hospital and skilled nursing facility claims data for Medicare claims. Collects information on Medicare providers that includes charges, patterns, and claims.
What is the NPDB?
National Practitioner Data Bank (NPDB) - mandated under the Healthcare Quality Improvement Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and certain professional review actions taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers as well as private accrediting organizations and peer review organizations. Law requires healthcare facilities to quarry the NPDB as part of credentialing process when a physician initially applies for medical and staff privileges and every two years.
What is an Operation index?
Operation index - Similar to the disease index expect that it is arranged in numerical order by patient procedure codes. Surgeon may be listed in addition to, or instead of the attending physician
What is a Patient-specific/identified data or Patient identifiable data ?
Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address
What is an Physician Index?
Physician Index - Listing of cases in order by physician name or physician identification number. May also include the patient's health record number and date of discharge. Enables users to retrieve information about a particular physician, including the number of cases seen during a particular time period.
What is a Population-based Registries?
Population-based registries - A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region
What is the Primary Data Source?
Primary Data Source - A record developed by healthcare professionals in the process of providing patient care
What is a Protocol?
Protocol - The trial proceeds according to a protocol, a list of rules and procedures to be followed.
What is Public Health?
Public health - An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties
What is the comprehensiveness of the data?
Referred to as completeness. Missing data may prevent the database from being useful fro research or clinical decision making
What is Accuracy of the data?
Referred to as data validity, means that data is correct (Example - Cancer registry, the stage of the neoplasm must be recorded accurately because statistical information on survival rates by stage is commonly reported)
What is a Secondary Data Source?
Secondary Data Source - Data derived from the primary patient record, such as an index or a database