403 4-6
Disease Indexes
Retrieve diagnoses coded with ICD-9 dx codes
Operations Indexes
Retrieve operations coded with ICD-9 px codes or CPT codes
5 rights
Right dose 2. Right drug 3. Right patient 4. Right time 5. Right route
CPT
Current Procedural Terminology
Master Patient Index (MPI)
- Listing of all patients seen at a facility - Basic demographic data - name, address, date of birth, gender race, primary language, place of birth, religion, marital status - May include insurance and provider
Standardized data sets
- Uniform data commonly collected across HC settings • Must be uniform if data are combined - Used for meaningful comparisons • For assessing performance across institutions - Can be primary, secondary or a combination of data
Minimum Data Set for Long-Term Care (MDS 3.0)
-> data collect from nursing homes • Federally mandated standardized assessments for facilities providing services in residential settings (people not capable of living independently) requires comprehensive functional assessment at admission and at intervals throughout stay • Used for pt's (resident's) care plan - Has more clinical data than in UHDDS and UACDS • Supports documentation of these assessments • Supports placement of pt at appropriate level of care
secondary data
-Data from another source that is re-purposed -information that already exists somewhere, having been collected for another purpose - Data from patient record entered into another database
What is CPT-4 used for?
A coding system used to describe hospital based outpatient services and physician office visits. Medicare Part B physician office and other ambulatory care sites.
Database
A collection of organized data that allows access, retrieval, and use of data
UACDS
A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient- or client-specific data elements to be collected in ambulatory care settings. • For care provided in facilities for patients who return home the same day - Physicians' offices, same day surgery centers, hospital OPD, EDs • Goal - to improve the comparability of data collected across ambulatory care and OPD settings - Physicians' offices, same day surgery centers, hospital OPD, EDs • Why important? - Shift of care from IPD to OPD • Technological advances - Short-acting anesthesia - Procedural improvements • 3 rd party payors pay for most px done OPD • Medicare Prospective Payment System (PPS - this is the Diagnostic Related Group (DRG) reimbursement mechanism) limits payment for IPD, encourages ambulatory care
Data Dictionary
A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use.
Data set
A group of individual values or bits of information that are related in some way or have some common characteristic or attribute. May be a data table or a relational database with many data tables.
Healthcare Integrity and Protection Data Bank (HIPDB)
A national source of reports of actions taken against healthcare providers, practitioners, and vendors who are in noncompliance or performing fraudulent activities
Computerized Provider Order Entry (CPOE)
A process by which the health care provider directly enters orders for patient care into the hospital information system. • Replaces handwritten and verbal orders - Removes some of the errors in translation » Illegibility of handwriting » Misinterpretation of speech • Incorporates decision-support capabilities - Dose checks, contraindication checks (e.g., based on allergies, conditions or other Rx) - Can be used to alert physician regarding needed preventive or other services • Pt shows up in clinic and is due for a flu shot, reminder can prompt dr to do order - Can alert physician regarding testing protocols • A lab test result could trigger the next logical test - Hepatitis screen that is positive would trigger more conclusive test
Point of Care Charting (POC)
A system whereby information is entered into the health record at the time and location of service • Where many hospitals/organizations begin with EHR development • Documentation of clinical findings - Includes things like nursing assessments, charting of vital signs, progress notes • Data recorded at the bedside
IDC-9-CM
Abbreviated title of International Classification of Diseases, Ninth revision, Clinical Modification, the source of the codes used for reporting diagnoses until October 1, 2014
Included in UHDDS because of availability
Admin date, dx, discharge disposition
Data element
An individual fact or measurement that is the smallest unique subset of a database.
Certified Tumor Registrars (CTR)
An individual who has achieved specialized skills in the cancer registry
Electronic Medication Administration Record (EMAR)
An interface that documents the time, dosage, and administration route for every medication administered to a patient in the hospital. • Barcodes can be used for charting • Incorporates the 5 rights of medication administration: - Right patient, right drug, right dose, right route, right time
Data Warehouses
Central repositories of integrated data from one or more disparate sources.
H.I. specialist in cancer registry
Certified Tumor Registrars
IDC-9-CM is
Codes dx and px, organized by body systems Basis of DRG assignments for inpatient reimbursement Dx codes used in all care settings Px codes used in hospital setting
Registries
Collection of secondary data, Can be facility-specific, local, regional, state, national - Generally extensive, specific information collected
Cancer Registries
Collection of: Demographic information Industrial or occupation hx (as recorded in record) Date of dx, source of dx Cancer site, stage (how extensive is cancer), type of treatment Used to track the disease, treatment and outcome.
Patient-specific and identifiable
Contains name or other link to patient ID
Certified Tumor Registrars (CTR)
Credentialed health information professionals that work in cancer registries
Information
Data converted into a meaningful and useful context
Aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Aggregated
Data on groups of people - no individual identification
Database Management Systems
Data tables with their table structures, data dictionaries, relationship diagrams, computer language for manipulation, administrative information (who is owner, where does it live, who gets access)
Facility specific indexes
Databases established by healthcare facilities to meet their individual, specific needs for customer care or other reporting requirements.
Birth Defect Registries variables
Demographic information Diagnoses codes for defect BWT, status of infant at birth (stillborn, live born) Whether infant was single or multiple birth Autopsy Cytogenetics results (testing for genetic conditions) Mother's and father's use of alcohol or illicit drugs Mother's use of tobacco Family hx of birth defects
Billing code for wheelchair
HCPCS code
What is HCPCS used for?
Developed by Medicare as a supplement to the CPT system for procedures not defined with sufficient specificity such as medical services, equipment and supplies.
Picture Archiving and Communication System (PACS)
Electronic network for communication between the image acquisition modalities, display stations, and storage. • Can improve over traditional film-based imaging - Higher resolution, full motion video capacity (like for dynamic studies like cardiac cauterization) • Remove images of structures that interfere with image of interest (e.g., ribs on chest films) - Can rotate and enlarge images - Can view more than one image at once • For comparison exams - (has a finding on an x-ray take one year ago changed)
Why was IDC-9-CM replaced?
Enhancements were needed to improve coding accuracy IDC-10 as almost twice as many categories as ICD-9 More expandable - ICD-9 has run out of codes
What was the challenge with the ICD-10 vs. ICD-9 structure?
Extra two spots caused problems wit US computer systems.
Data
Facts and statistics used for reference or analysis.
An example of aggregate data
Frequency of the number of patients seem by the orthopedic department broken down by gender and race
Human Resources (HR) Management Systems
Functions - Manage personnel - Pay staff - Analyze labor costs by divisions (cost centers) • Management of employees - Personnel records • Date of hire and termination, salary, title, family information - Rehire eligibility - Employee evaluations • Track evaluation process • Track attendance/productivity required for evaluation - Qualifications and credentials • License info, board certification info, practicing privileges - NPDB, HIPDB • Continuing Medication Education (CME) and Continuing Education (CE) tracking
Billing ambulance services uses
HCPCS
HCPCS
Healthcare Common Procedure Coding System
The role of Standardized data sets with in the NCHS.
Historical to compare data across different facilities and over time. • Recommended that all acute, short-term hospitals collect a minimum set of data elements • Recommended that data elements should be reflected in hospital discharge abstract systems
How is IDC-10 more specific then IDC-9?
IDC-10 as almost twice as many categories as ICD-9 Combination codes added A single code can be used to classify 2 diseases Such as a symptom or diagnosis with a complication Adds laterality - right, left, bilateral Expanded codes to add more detail in some sections - injuries, diabetes, post-op complications
Administrative information systems
Information used for administrative and healthcare operations purposes, such as billing and quality oversight Finance - Human resource management - Larger scale (enterprise-wide) decision support - "executive decision support" or "expert systems"
Facilities Management Systems
Is maintaining all facilities and property and ensuring that everything is in proper operating order. This includes all physical buildings, equipment, and exterior grounds of a facility. • For organization, management and maintenance of physical plant • Functions - Preventive maintenance - Energy maintenance - Project management and scheduling • From mundane to sophisticated - From painting and repair of parking lot to maintenance of infusion pumps and CT scanners
What is DSM-IV and V?
Listing of criteria for diagnosing mental dx of ICD - Allows framework for systematically evaluating pt to establish the dx
Data dictionary
Listing of data elements, definitions, format (size, type)
Coding systems
Makes for easy retrieval of data, billing processes, storage in a DB(database)
Info sys. with the medical record # and demographic info for all pt. seem at a facility
Master patient index (MPI)
Patient Management Systems
Master patient index, ADT, R-ADT (Registration-admission, discharge, and transfer system), Patient registration, Practice Management System - Appointment scheduling services - Patient services • Dr. locator, Pt education, Pt satisfaction • Price information
EMAR documents what
Meds given
Billing code for Tylenol
NDC coding
NDC
National Drug Code Codes for drugs
NPI
National Provider Identifier (health care provider 10 digit lifetime number issued by CMS, billing)
Primary data
Original data - For HC, the patient record - care that is documented by provider at time of encounter - Source data
Identifier Standards
Pt identifier • Not the SSN may be a Identification Number
Implant Registries
Pts with inserted devices - breast implants, heart valves, pacemakers, joints - Used for tracking performance of implants including complications, deaths, defects, recalls • Subset of facilities required by Food and Drug Administration (FDA) to report deaths and severe complications due to a device to manufacturer
Clinicaltrials.gov
Purpose: Information for patients and providers • Data: protocol identification number, sponsor, condition, intervention, criteria for entry, number of subjects for recruitment, recruitment status - Searchable by condition and sponsor (funding agency)
Could be used to track a patient with in a health care system.
R-ADT
Picture achieving is associated with what
Radiology systems
R-ADT
Registration-admission, discharge, and transfer system
Clinical information systems
Technology based system applied at the point of care & designed to support the acquisition & processing of information capabilities. - Pt management • E.g., order entry for physicians, medication management - Department-specific • E.g., lab, radiology
National Center for Health Statistics (NCHS)
The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States.
HR sys. would likey
Track employee evals, hire/ fire tracking, credentials tracking
Mandated to collect inpatient data for Medicare/Medicaid
UHDDS
Provider identifier
Unique Provider Identification Number (UPIN) - Originally developed for to bill for services to Medicare
Uniform Hospital Discharge Data Set (UHDDS)
Was developed to: Improve the consistency and comparability of healthcare data; Designed to collect a minimum set of data about inpatients. • Pt ID • Demographic data (DOB, gender, race, ethnicity, residence) • Hospital ID, physician ID (UPIN) • Attending physician, operating physician • Admission date, type of admission • Principal dx - dx chiefly responsible for hospitalization • Other dx with qualifiers (explanatory fields) - Indicate whether dx was present at admission or occurred during stay - External injury code (e.g.. poisoning, fall) • Birth weight for neonates (recorded in grams, preferably) • Procedures and dates • Disposition of pt (deceased, home, AMA...) • Expected payment source (insurance, private, no payment expected) • Total charges - charges billed for this hospitalization, excludes physician professional charges
e-prescribing advantages
ability to quickly perform safety checks, 5 rights of medication administration, bar code charting,
Info on research study recruitment would be found at
clinicaltrials.gov
Stats collected by MDCH
cancer by county, birth, death, marriage, divorces
Practice Management System
comprehensive system to organize a single physician or group practice - serves a variety of functions - Pt appointment scheduling - Pt registration - Billing • Coding of dx and px at visits - Optimization and compliance » Most appropriate code at highest payment level
dx
diagnosis
NCD codes code what
drugs
International Classification of Diseases - Oncology (ICD-O-3)
for coding cancer sites and tissue type
Coding standards
guidelines for composing HC codes (ICD, CPT4, HCPCS, NDC)
Main purpose of R-ADT
management of pt location and management od beds
px
prognosis
4 components of R-ADT
registration, admission, discharge, transfer.
Lab sys. would
report test results, monitor test quality, track turnaround time
MDCH: Behavioral Risk Factor Survey would collect data concerning
smoking status, screening exams, self-reported general health
Transplant Registries
• 3 aspects - People needing organ - Potential donors - Transplanted persons • Often national or regional due to need to match up donors with recipients • Priority rating used to allocate organs equitably
Laboratory Systems
• Collecting, verify and reporting test results - Order entry, could receive orders from CPOE - Processing specimens • Tracking - can incorporate b ar code technology where label on vial has pt ID information - Results • Results inquiry • Reporting to clinicians - Electronic access and report generation - Interpretive warning indicators -Graphical display of cumulative pt results -Follow-up with pt (track notification, close communication loop) - Monitoring test quality • Alerts for inappropriate or inadequate specimens • Lab management tasks - Inventory - Monitoring work flow (test turnaround time) - Laboratory staff productivity
Public Health Databases
• Data maintained at national, state, county level • Developed by public health departments • Types of data and reporting - Disease incidence (new cases) • Surveillance statistics and trends over time - Survey data on risk characteristics of population • MDCH: Behavioral Risk Factor Survey (BRFS) - 6,000 telephone interviews, conducted annually - Vital statistics - State reports to NCHS • Births Deaths Fetal deaths Marriages Divorces
Immunization Registries
• Goal - increase immunizations in infants and children • Registries can facilitate by being central source of immunization information • Across providers - providers can see what is needed based on child's vaccine history • National Immunization Program - CDC with National Vaccine Advisory Committee
Patient-specific and deidentified
• Linkage not possible • "statistically deidentified" data associated with a patient but the patient can be identified
Radiology Department Systems
• Manage films, reports and/or images • Newer and future technologies - Generate digital images (digitized x-rays) • Allows films or images to be viewed from computer screen • Makes it unnecessary to store images on film • Analyze images - Computer would see and analyze what radiologist sees visually
National Practitioner Data Bank (NPDB)
• Mandated under Health Care Quality Improvement Act of 1986 • Database for recording "wrong-doings" - Covers physicians, dentists, pharmacist, physical therapists and other providers - Rationale: Physicians could lose license in one state and set up practice or get staff privileges in another without new setting being aware of incident Does this happen? • Scope of entries: • Malpractice payments • Sanctions taken by board of medical examiners (e.g.. loss of license) • Denial of staff privileges
Birth Defect Registries
• Newborns with birth defects - Can be population-based (such as within the MI Department of Community Health (MDCH)) - Used for determining incidence of birth defects, targeting prevention programs • Data elements of interest: Demographic information Diagnoses codes for defect BWT, status of infant at birth (stillborn, live born) Whether infant was single or multiple birth Autopsy Cytogenetics results (testing for genetic conditions) Mother's and father's use of alcohol or illicit drugs Mother's use of tobacco Family hx of birth defects
Pharmacy Department Systems
• On-line order entry (CPOE) - Drug compatibility checks - Drug indication checks • Contraindication checks (such as allergies or competing health problems) • Interactions/drug-drug compatibility checks - Dose checks (recommended vs. prescribed) • Control inventory • Profile drug dispensing practices - Use of expensive drugs, changing patterns - Overuse of contraindicated drugs • E.g., antibiotics for viral infections (10% of infections are bacterial)
Financial Management Systems
• Pt accounting systems: - Accounts Payable • Generates invoices - Accounts Receivable • Maintains records of all customers • Manages payments - Splitting for multiple payments for insurance(s) and pt portions of bill - Collection agency handling - Bad debtor alerts • General Ledger • Financial accounts management
Indexes
• To allow for retrieval of specific groups of patients • Today, computerization eliminates (mostly) the need for a specific content as source data can be accessed - exception to this would be MPI