HIT-101 Chapter 8

Incidence:

The number of new cases of a specific disease

Abstracting:

The process of extracting elements of data from a source document or database and entering them into an automated system

Credentialing:

The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services

Data stewardship:

The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information

American College of Surgeons (ACS)commission on cancer:

The scientific and educational association of sur- geons formed to improve the quality of surgical care by setting high standards for surgical education and practice

National Library of Medicine (NLM):

The world's largest medical library and a branch of the National Institutes of Health

Population-based registry:

A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region

Traumatic injury:

A wound or injury included in a trauma registry

Public health:

An area of healthcare that deals with the health of populations in geopoliti- cal areas, such as states and counties

Certified Tumor Registrar (CTR):

An individual who has achieved specialized skills in the cancer registry

Stakeholder:

An individual within the company who has an interest in, or is affected by, the results of a project

National Cancer Registrars Association (NCRA):

An organization of cancer registry professionals that promotes research and education in cancer registry administration and practice

Index:

An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data

Database:

An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications

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 inju- ries of each patient

Vital statistics:

Data related to births, deaths, marriages, and fetal deaths

Claim:

Itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted for reimbursement to the health- care insurance plan by either the insured party or by the provider

Histocompatibility:

The immunologic similarity between an organ donor and a transplant recipient

Facility-based registry:

A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic

Abbreviated Injury Scale (AIS):

A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system

Disease index:

A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use

Physician index:

A list of patients and their physicians that is usually arranged according to the physician code numbers assigned by the healthcare facility

Operation index:

A list of the operations and surgical procedures performed in a health- care facility that is sequenced according to the code numbers of the classification system in use

Interrater reliability:

A measure of a research instrument's consistency in data collection when used by different abstractors

Case definition:

A method of determining criteria for cases that should be included in a registry

Case finding:

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

Autodialing system:

A method used to automatically call and remind patients of upcom- ing appointments

National Vaccine Advisory Committee (NVAC):

A national advisory group that supports the director of the National Vaccine Program

North American Association of Central Cancer Registries (NAACCR):

A national organization that certifies state, population-based cancer registries

Collaborative Stage Data Set:

A new standardized neoplasm staging system developed by the American Joint Commission on Cancer

Accession number:

A number assigned to each case as it is entered in a cancer registry

Unified Medical Language System (UMLS):

A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand bio- medical concepts, words, and expressions and their interrelationships

Primary data source: e

A record developed by healthcare professionals in the process of providing patient car

Disease registry:

A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery

Stage of the neoplasm:

A classification of malignancies (cancers) according to the anatomic extent of the tumor, such as primary neoplasm, regional lymph nodes, and metastases

Medicare Provider Analysis and Review (MEDPAR) File:

A collection of data from reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care being provided

Facility-specific system:

A computer information system developed exclusively to meet the needs of one healthcare organization

Vendor system:

A computer system developed by a commercial company not affiliated with the healthcare organization

Medical Literature Analysis and Retrieval System Online (MEDLINE):

A computerized, online database in the bibliographic Medical Literature Analysis and Retrieval System (MEDLARS) of the National Library of Medicine

Edit:

A condition that must be satisfied before a computer system can accept data

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

National Practitioner Data Bank (NPDB): s

A data bank established by the federal gov- ernment through the 1986 Health Care Quality Improvement Act that contains information on professional review actions taken against physicians and other licensed healthcare practitioners, which healthcare organizations are required to check as part of the creden- tialing proces

Healthcare Integrity and Protection Data Bank (HIPDB):

A database maintained by the federal government to provide information on fraud-and-abuse findings against U.S. healthcare providers

Centers for Disease Control and Prevention (CDC):

A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States

Healthcare Cost and Utilization Project (HCUP):

A group of healthcare databases and related software tools developed through collaboration by the federal government, state governments, and industry to create a national information resource for patient-level healthcare data

Accession registry:

A list of cases in a cancer registry in the order in which they were entered

Data timeliness:

Concept of data quality that involves whether the data is up-to-date and available within a useful time frame; See data currency

Secondary data source:

Data derived from the primary patient record, such as an index or a database

Protocol:

In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial; in a computer network, a protocol is used to address and ensure delivery of data

Demographic information:

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person

Patient-specific/identifiable data:

Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address

Health services research:

Research conducted on the subject of healthcare delivery that examines organizational structures and systems as well as the effectiveness and efficiency of healthcare services

Activities of daily living (ADL):

The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating

Agency for Healthcare Research and Quality (AHRQ):

The branch of the United States Public Health Service that supports general health research and distributes research

Transparency:

The degree to which individual patients are made aware of how their per- sonal health information is or has been dispersed to secondary medical databases

Data confidentiality:

The extent to which personal health information is kept private

National Center for Health Statistics (NCHS):

The federal agency responsible for col- lecting and disseminating information on health services utilization and the health status of the population in the United States

Food and Drug Administration (FDA) : T

he federal agency responsible for controlling the sale and use of pharmaceuticals, biological products, medi- cal devices, food, cosmetics, and products that emit radiation, including the licensing of medications for human use