HIMT Chapter 6 Overview

Uniform Ambulatory Care Data Set (UACDS)

collects data specific to ambulatory care settings with an intent to improve data comparison across different settings

query

communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, clarify documentation, or ask additional questions regarding documentation • types: paper and electronic

standards development organizations (SDOs)

private or governmental agencies that are involved in the creation and implementation of healthcare standards

Essential Medical Data Set (EMDS)

collects data for emergency care settings

Data Elements for Emergency Department Systems (DEEDS)

collects data for hospital-based emergency rooms

Outcomes and Assessment Information Set (OASIS)

collects data from home healthcare settings

Minimum Data Set (MDS)

collects data from long-term care settings

databases

a collection of data that are organized in such a way that its contents can be easily accessed, managed, reported, and updated two types: relational and object-oriented

National council for Prescription Drug Programs (NCPDP)

a committee within the Designated and Standard Maintenance Organization focused on the development of standards regarding exchanging prescription information and payment information created multiple standards including: • a standardized data dictionary for pharmacy data • standards for transactions of file submissions between pharmacies and processors • standards for common billing unit language for submission of prescription claims • standards to communicate formulary and benefit information to prescribers

master patient index

a guide to locating specific demographic information about a patient, such as the patient name, health record number, DOB, gender, and dates of services

physician index

a listing of all physicians within an organization with all the diagnosis and procedure codes linked to the provider within the index • includes physician's identification (code or name), health record number, diagnosis, operations, dates of service, patient gender, patient age, patient outcome form encounter • can be used to produce information regarding the work of the provider within an organization, which can be useful for certification and credentialing purposes

data dictionary

a listing of all the data elements within a specific system that defines each individual data element, standard input of the data element, and specific data length

operation or procedure index

a listing of specific codes for procedures or operations performed within the facility • includes similar information as the disease index, but also includes the specific code numbers as well as the operating physician • can be used to query specific information regarding procedures or operations done within the facility

disease index

a listing of specific codes that link a specific disease or diagnosis to a patient • includes diagnosis codes, health record number, gender, age, race, attending physician, hospital service, patient outcomes, dates of encounter • can be used to query a specific diagnosis to determine other attributes of patients with the disease

object-oriented database (OODB)

a major type of database that operates by storing data in objects rather than in tables • stores different types of data including images, audio files, documents, videos, and data elements • dynamic because it provides the data as well as the object (image and document)

Institute of Electrical and Electronics Engineers (IEEE)

a national organization that creates and develops different standards for hospital systems that need communication between bedside instruments and clinical information systems • currently has standards that allow providers and hospitals to achieve interoperability between medical instrumentation and computer healthcare information system • though used in multiple types of systems, it is most often used within acute-care settings

data mapping

a process that allows for connections between two systems

clinical documentation improvement (CDI)

a program designed to ensure the quality and integrity of the patient data while supporting healthcare operations such as coding and reimbursement

data sets

a recommended list of data elements that have defined and uniform definitions that are specific to a type of healthcare industry

index

a report or list from a database that provides guidance, indication, or other references to the data contained in the database • serves as a guide or indicator to locate something within a database or other systems storing data • support daily operations for healthcare organizations and are tools used to gather specific information quickly

data

a representation of basic facts and observations about people, processes, measurements, and conditions

data warehouse

a single database that makes it possible to access data that exists in multiple databases through one single query and reporting interface

data element

a single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as raw facts and figures examples: age, gender, blood pressure, temperature, test results, DOB

database life cycle (DBLC)

a system consisting of several phases that represent the useful life of a database • initial study • design • implementation • testing and evaluation • operation • database maintenance and evaluation

relational database

a type of database that stores data in predefined tables made up of rows and columns; typically regarded as two-dimensional

definition

all data elements should be clearly defined to guarantee that all individuals using and collecting the data will understand the meaning of that data element

data information exchange

allow for electronic exchange of information between providers' electronic systems • needed to support interoperability

Health Level 7

an ANSI-accredited SDO that was founded in 1987, established for the creation of standards to support the exchange of clinical information in multiple formats

information governance

an organization-wide framework for managing information throughout its lifecycle and supporting the organization's strategy, operations, regulatory, legal, risk, and environmental requirements

clinical documentation

any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient's medical condition or treatment

interoperability

capability of two or more information systems and software applications to communicate and exchange information

comprehensiveness

certifies all required data elements that should be collected throughout the health record are documented

data strategy

clearly defines the organization's data policies and procedures, roles and responsibilities for data governance, business rules for data governance, process for controlling data redundancy, management of key master data, use of structured and unstructured data, storage for all healthcare data, and safeguards and protections of the data

data standardization and integration (data strategy)

concept that focuses on how the data is being entered into the system, where the data is going within the system, where the same data might exist in multiple areas, and how it is being integrated into other applications • the intent is to document the location of data collection and ensure standardized formats and meaning of the data

electronic query

conducted through an EHR and allows the healthcare provider to offer more clarification or specific information regarding the patient's treatment and diagnosis

principle of transparency

create a clear and open documentation process for information governance strategy and activities within an organization • processes should be established to provide clear documentation and evidence that supports the organization's operations, decisions, activities, and performance as it relates to the creation, implementation, and maintenance of the information governance program

principle of compliance

create a process for ensuring that all the information complies with appropriate laws, regulations, standards, and organizational policies

principle of retention

create a process for proper retention of information based on requirements from regulations, accrediting organizations, and company policy

principle of integrity

create assurances that the data generated and maintained by an organization maintains authenticity and reliability

principle of accountability

create authority over the information governance process within an organization • a member of senior leadership should be assigned to oversee and implement a complete information governance program that aligns with the organization's goals and strategies

principle of availability

create processes and procedures to ensure that information is available when needed, and also accurate, timely, and can be retrieved with ease

principle of disposition

create processes for secure and appropriate disposition of information that is no longer needed to be maintained by the organization based on regulations and organizational policy

principle of protection

create protections to safeguard data and information from improper use and disclosure to avoid data breaches

data stewardship

creation of responsibility of data through principle and practices to ensure that the appropriate knowledge and use of the data from personal health information is being used appropriately

information assets

information collected during day-to-day operations of a healthcare organization that has value within an organization

precision

data should be precise and collected in its exact form within the course of patient care • when information is entered precisely, there should be little to no variability of the data

provider contracts with facilities

delineate all expectations of the provider as they care for patients in a specific ambulatory care setting

medical staff bylaws

describe the manner in which providers will practice medicine within an organization that aligns with the mission and values of the organization

initial study

determining need for database

data exchange standards

developed in order to support and create structure with data exchanges to sustain interoperability • goals are to facilitate consistent, accurate, and reproducible capture of clinical data • help support data integrity and safeguard data quality when sharing between organizations

implementation

development of database

collection

domain of data quality management concentrates on where and how the data elements are being collected throughout the encounter

application

domain of data quality management focused on understanding the purpose of the data collection

analysis

domain of data quality management which centers on how the data collected throughout the patient encounter is transformed into meaningful data for use throughout the entire spectrum of the healthcare setting

warehousing

domain of data quality management which describes the processes as well as systems an organization uses to archive data; it also includes understanding where the data is being stored, and how it is being archived as well as managed

testing and evaluation

ensuring system works as expected

data quality

ensuring the information entered into the patient's record is reliable and has integrity in order to support patient care, patient safety, and provide evidence for reimbursement and accreditation

consistency

ensuring the patient data is reliable and the same across the entire patient encounter • patient data within the record should be the same and should not contradict other data also in the patient record

administrative data elements

example: billing data and quality improvement data

clinical data elements

example: data about a patient visit in an electronic health record

data quality (data strategy)

focuses on entering data into the system that is true, accurate, and relevant to patient care needs and business operation needs

healthcare-specific data

focuses on patients, which includes demographic, financial, and clinical data

accuracy

focuses on the data being free of errors

design

identify data fields, structure, and so forth

target data

location from which the data is mapped or to where it is sent

source data

location from which the data originates, such as a database or data set

data sources

locations where data is being generated and stored within an organization • includes clinical and administrative

timeliness

patient documentation should be entered promptly, ensuring up-to-date information is available within specified and required time frames

accessibility

proper safeguards must be established and employed to assure the data is available when needed while implementing proper precautions and safeguards to protect the information

information

refers to data elements that have been combined and then manipulated into something meaningful regarding a patient or a group of patients

metadata management (data strategy)

refers to managing and defining the metadata within the system • it is important to clearly define what metadata will be collected and why it is being collected

data modeling (data strategy)

refers to the creation of documentation to justify business decisions made based on the different data collection and storage systems that are used within an organization • creation of data models and defining the use of data in relation to business mission and vision allows for the support of data standardization across the organization

enterprise information management

set of functions created by an organization to plan, organize, and coordinate the people, processes, technology, and content needed to manage information for the purposes of data quality, patient safety, and ease of use

AHIMA's Data Quality Management Model

supports the need for true and accurate data - defines four domains that link and support data quality • application • collection • warehousing • analysis - defines ten characteristics of quality data • accuracy • accessibility • comprehensiveness • consistency • currency • definition • granularity • precision • relevancy • timeliness

data integrity

the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so • includes: data governance, patient authentication, authorship validation, amendment and records correction, audit validation

data quality management

the business process that ensures integrity of an organization's data during collection, application, warehousing, and analysis

data ownership (data strategy)

the creation of business owners over specific areas of the data • based on the business need, the business owners are responsible to create business rules and definitions when collecting specific data to support patient care and their patient operations • closely connected to data stewardship

granularity

the data collected for patient care must be at the appropriate level of detail

metadata

the data that characterizes other data, such as creation date of data, date sent, date received, last accessed date, last modified date

currency

the data within the record needs to be current and up to date • specific procedures should be established for updated data elements used for each patient encounter, including the discontinuation of collected data elements that are no longer current

data management

the definition and structure of data elements and the creation, storage, and transmission of data elements

data stewardship (data strategy)

the evaluation of the data collection based on business need and strategy to ensure the data meets the requirements of patient care and organizational needs • closely connected to data ownership

relevancy

the extent to which the data elements being collected are useful for the purposes for which they are collected • if a healthcare organization collects data that is not relevant in supporting patient care and administration, it adds additional, unnecessary information to the record

Digital Imaging and Communication in Medicine

the messaging standard for digital images; it is used by vendors, user organizations, government agencies, and trade associations to share radiology and other digital images such as cardiology

critical thinking

the process of analyzing, assessing, and reconstructing a situation to provide enhanced solutions and outcomes to a problem

data warehousing

the process of collecting the data from different data sources within an organization and storing it in a single database that can be used for decision making

system characterization

the process of creating an inventory of all systems that contain data, including • documenting where the data are stored • what type of data are created or stored • how they are managed • with what hardware and software they interact • providing basic security measures for the systems helps identify all sources of data that exist within a healthcare organization

data mining

the process of extracting from a database or data warehouse information stored in discrete, structured data format (data that has a specific value)

database maintenance and evaluation

updating and backing up database and ensuring that it still meets needs

operation

use of database

paper query

uses a standardized physical document to request clarification or further specify a diagnosis

hospital bylaws

written documents that govern the staff members who create data within the record for additional support of patient care and reimbursement

bylaws

written documents that provide details and information regarding the rules and regulations established by a healthcare organization to help support healthcare operations • can support and facilitate the collection and assurance of quality data

common standards development organizations

• Health Level 7 • Digital Imaging and Communication in Medicine • Institute of Electrical and Electronics Engineers (IEEE) • National Council for Prescription Drug Programs (NCPDP)

common data sets in healthcare

• Uniform Hospital Discharge Data Set (UHDDS) • Uniform Ambulatory Care Data Set (UACDS) • Data Elements for Emergency Department Systems (DEEDS) • Minimum Data Set (MDS) • Outcomes and Assessments Information Set (OASIS) • Essential Medical Data Set (EMDS)

AHIMA's information governance principles

• accountability • transparency • integrity • protection • compliance • availability • retention • disposition

data strategy components

• data standardization and integration • data quality • metadata management • data modeling • data ownership • data stewardship

common data sources in healthcare

• electronic health record (EHR) • practice management system • lab information systems • radiology information systems • picture archival and informations (PACs) • other clinical documentation systems (home health, therapy, long-term care) • master patient index • other patient index (indices) • databases • registries

data management — organizations need to know and understand

• how data is produced • why certain types and formats of data are produced • how data are stored and managed • how to ensure data integrity

common healthcare indices

• master patient index • disease index • operation or prodecure index • physician index

clinical documentation improvement (CDI) goals

• obtain specific documentation that can be used to identify the patient's severity of illness • identify missing, conflicting, or unclear documentation • support code assignment and reimbursement • facilitate health record completion • support communication between care providers • facilitates education • improve quality of care

data warehouse advantages

• one consistent data storage area for reporting, forecasting, and analysis • easier and timely access to data • improved end-user productivity • improved information services productivity • reduced costs • scalability • flexibility • reliability

Uniform Hospital Discharge Data Set (UHDDS)

• one of the first defined and used data sets across the US healthcare industry • implemented in the mid-1970s • collects uniform data elements from the health records of every hospital inpatient

data governance

• process for ensuring that control and accountability for enterprise data management is established throughout an organization • focuses on how healthcare organizations create processes, policies, and procedures for keeping information that is relevant to patient care and healthcare operations

common types of bylaws used

• provider contracts with facilities • medical staff bylaws • hospital bylaws