Health Data Content & Structure

Data

plural form datum

Data Governance purpose

"Data governance (DG) is the sub-domain of information governance (IG) that provides for the design and execution of data needs planning and data quality assurance in concert with the strategic information needs of the organization". (AHIMA.org) •"The purpose of Data Governance is to implement effective data management, ensuring that data is of high quality, accurate and reliable".

Data management

*data elements *data sets *Indices (Indexes) *data mapping *data warehouses

goals of using data interchange standards

-Create a basis to enable the electronic exchange of data between 2 or more computer systems by creating consistent formats and sequence of data that are applied during data transmission. -Ensure that the existing clinical and administrative data contained in both paper and electronic data systems to maintain patient data consistency in growing EHRS, -Transfer health data using appropriate business processes and necessary ethical and regulatory demands and guidance -Foster electronic transmission as a business strategy to support patient care and better patient outcomes -Promote efficient information sharing among individual computer systems and institutions

standardized definitions of data elements

A data dictionary supports the creation of well-structured and defined data sets by creating standardized definitions of data elements to help ensure consistency of the collection and use of the data

Database

A database is an organized collection of data organized so that its contents can easily be accessed, managed, reported and updated

use case

A tool called a use case, will help creators of data maps to better understand the flows and interactions between systems. •A use case is a description of the steps between a user and computer software to accomplish a process.

Data Integrity..

Data Integrity is 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.

Data Interchange Standards

Data Interchange Standards are needed to support interoperability between healthcare organizations .•Interoperability is the capability of two or more information systems and software applications to communicate and exchange information .•Standard development organizations (SDO) have created standards for the sharing of information in electronic formats. •These organizations are private or government agencies that are involved in the creation and implementation of healthcare standards to support the process of electronic exchange of data.

Data element

Data element is a single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as the raw facts and figures •Examples o Age o Gender o Blood Pressure

data governance

Data governance is an organization's control and accountability for their enterprise data through established data policies and standards that are monitored, and implemented through a formal structure of designated roles, responsibilities and accountabilities. The goal of data governance is maintaining data accuracy and removing unnecessary data from the health record

Data Mapping

Data mapping is a process that allows for connections between two systems. Mapping is the process of identifying relationships between two distinct data models. Mapping is necessary as healthcare information systems and their use evolves in order to link different systems and data sets

Data Stewards

Data stewards are those people within the organization who are responsible for a specific system or a specific set of data. •The data steward is the expert in the data governance that they are responsible for.

Defining data dictionary

Defining data dictionary can help with accuracy of patient data and create support for data comparison and data sharing. Data dictionary is the basic step to understanding data elements, their meaning and usage

Data modeling:

Documentation developed within a business based on data collection and storage systems within the organization. Models of the data are created to define the facility's use of data in relations to their mission and vision and allows for support of data standardization across the entire facility

Data Sharing/Data Information Exchange

EHRs allows for electronic exchange of information between healthcare organizations despite information systems used. •Data sharing is the electronic exchange of information between providers' electronic systems to help support and deliver quality healthcare .•It is known as health information exchange, (HIE) •Data sharing or HIE has 2 basic components: -The ability of 2 or more IS to communicate and exchange patient information -The ability of 2 or more IS to effectively collect and use the information that has been exchanged

Data Visualization and Presentation

Example: to present the frequency of a specific diagnosis by gender, a pie chart- meant to show the %, would not be a good selection. A table would be a better choice.

Database Management

For proper database management, it is important that an organization knows what databases exists, the purpose of the databases, the storage and backup of the databases, and who accesses and uses them A poorly designed database will result in both a redundant collection of data and data information errors

Data Integrity guidelines

Guidelines an organization can establish to reduce the likelihood related to damages to patient data include: -Committed to complying with laws and regulations, and in an ethical manner -Requiring accurate data -Holding individuals accountable for errors as per medical staff bylaws or rules and regulations -Identifying penalties for the falsification of information -Requiring periodic training -Defining management responsibility

DBLC HIM Professionals

HIM professionals have the responsibility of ensuring proper data collection, data privacy, security and data integrity. • It is important for HIM professionals to be involved in all stages of the database life cycle so as to secure the knowledge and skills to understand the essential steps of data collection, privacy, security and integrity of a database.

Data Integrity & Hippa

HIPAA requires that organizations implement policies and procedures to protect electronic health information from improper alteration or destruction and establish security measure to ensure that electronically transmitted electronic health information is not improperly altered.

Data Stewardship

Health data stewardship is a part of the data governance process. Is is a responsibility, guided by principles and practices, to ensure the knowledgeable and appropriate use of data derived from individuals' personal health information. These uses include (but are not limited to) data collection, viewing, storage, exchange, aggregation, and analysis.

Common Standards Development Organizations

In the U.S., SDO are managed by the American National Standards Institute (ANSI) Some common standard development organizations (SDO) are: •Health Level 7: the most common healthcare standard across systems. The standards consists of rules for transmitting demographic data, orders and patient observations, i.e. lab results and H&P findings. It also has message rules for appointment scheduling, referrals, problem list maintenance and care plans .•Digital Imaging and Communication in Medicine: supports retrieval of information from imaging devices and equipment. DICOM viewers enable clinician from a location to view digital images

Information assets

Information collected during day-to-day operations of a healthcare organization that has value within an organization .•Example: Patient data collected to support patient care for the healthcare organization. •Without the patient data, the organization would not be able to support continuity of patient care or the billing of services provided to the patient

organization-wide framework

Information governance can also be described as an organization-wide framework for managing information throughout its lifecycle and supporting the organization's strategy, operations, regulatory, legal, risk, and environmental requirements

Information

Information is different than data. It refers to data elements that have been combined and manipulated into more meaningful formats.

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 a data set

Common Indices

Master patient index •Disease index •Operation or procedure index •Physician index

outside agencies

Outside agencies that use health care data include third-party payers, government agencies, accreditation organizations and others within the healthcare industry to support and advance the healthcare delivery system and improve patient care.

2 common databases

Relational Database Object-oriented database

System characterization

System characterization helps identify all sources of data that exist within the facility.

AHIMA's Information Governance Adoption Model Competencies

The 10 key organization competencies promoted by the American Information Governance Adoption Model (IGAM) o IG Structure o Strategic Alignment o Enterprise Information Management o Data Governance Data Governance •IT Governance •Analytics •Privacy and Security •Regulatory and Legal •Awareness and Adherence •IG Performance

Situation, Background, Assessment, Recommendation (SBAR)

The Situation, background and recommendation (SBAR) tool is an easy to use and understand tool that can help define the intent of the IG program and clearly articulate the entire process to gain organizational and executive support .•When using SBAR to support an IG initiative, it is important to be specific about the issue and directly link it to the specific IG principle.

challenge of managing healthcare data

The challenge of managing healthcare data in an electronic setting is the ability to navigate through the various areas of where the data are stored, such as EHRs, lab information systems, radiology information systems, and billing systems There are many formats, methods and processes to collect and store patient information, such as directly entering information, scanning information and uploading of transcribed documentation

Stewardship....

The goal of data stewardship is to create and build trust and transparency through the entire healthcare organization as it pertains to the use of health data.

Information Governance

The goal of information governance is to maintain data accuracy and provide trustworthiness of a healthcare organization's information .•Accurate and trustworthy information ensures patient care and safety, reduction of risk to the information, improving operational efficiency and achieving and maintaining a competitive advantage in healthcare.

Time of Discharge

The time of discharge could mean several things, i.e. the time the discharge order was written, the time the order was entered into the I.S., or the time the patient actually left the nursing unit. These times could vary widely, therefore it is important that the data dictionary defines which time should be used

Data Sets

The work of the National Center for Health Statistics and the National Committee on Vital and Health Statistics in the 1960s made it evident that standardization in the structure and collection of data elements was needed to collect consistent data to allow for comparison across all healthcare organizations in the U.S.

data dictionary

To help support and manage data elements within an EHR, the use of a data dictionary is used to support standardized input and understanding of all data elements .•A data dictionary is 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

History of Common Data Sets

Uniform Hospital Discharge Data Set (UHDDS): first US data set implemented in the mid-1970s . During this time, uniform data elements from the patients' health records of every inpatient hospital was collected.

Data Sharing

When implemented correctly, a proper data sharing process can assist with coordinating patient information, analyzing patient information across multiple healthcare organizations and reducing unnecessary repeated tests to support improvement in patient outcomes and patient satisfaction.

Data quality

focuses on entering true, accurate and relevant data that is relevant to the needs of the patient as well as business operational needs

database life cycle (DBLC)

important step in the proper execution, implementation and management of databases within healthcare.

Information Governance Principles for Healthcare

in 2014 AHIMA established Information Governance Principles of Healthcare which were aligned with the Association of Records Managers Administrators (ARMA)

Data quality management

is "business processes that ensure the integrity of an organization's data during collection, application (aggregation), warehousing and analysis"

Data Quality --

is the reliability and effectiveness of data for its intended uses in healthcare operations, decision-making, planning and patient care.

data stewards rights

o An Individual has proper access to their PHI o An individual has a right to review and amend their PHI o An individual is provided transparency of information allowing them to understand what information will exist and how it will be used. o The individual must provide consent and authorization for use and disclosure of health information o Adequate information and education are provided regarding the rights and responsibilities of health information

common data elements within a data dictionary:

o Data field: (date of birth (01/01/2020) o Definition: (ex: patient's sex): Male, female, other) o Data type: (date, text, number, etc) o Format: (ex: MM-DD-YYYY) o Field Size: (ex: 10 digits for phone number) o Data values (Ex. M, F, T for gender) o Data Source (where data are collected) o Data first entered (when data element is first used) o Why item is included (justification for collection the data element)

includes...

o Data governance o Patient identification o Authorship validation o Amendment and records correction o Audit validation for reimbursement purposes

DBLC 6 STEPS

o Determine the need for the database (Initial study) o Design within the database (Identify data fields, structure , etc. o Implementation (development of database) o Testing and evaluation (ensuring system works as expected) o Operation (use of database) o Database maintenance and evaluation (Updating and backing up database and ensuring that it still meets needs)

Benefits of Data Stewardship

o Improved patient safety o Increased efficiencies o Decreased cost of care provided o Improved patient care and outcomes o Facilitated coordination of care o Structured data collection o Comprehensive data collection

Advantages of data warehouses

o One consistent data storage area for reporting, forecasting, and analysis o Easier and timely access to data o Improved end-user productivity o Improved information services productivity o Reduced costs o Scalability (perform anywhere from a small scale to large scale) o Flexibility o Reliability

Common Data Sets

o Uniform Ambulatory Care Data Set (UACDS): This data set began as patient care moved from acute care to ambulatory care o Data Elements for Emergency Department Systems (DEEDS): collects data for hospital-based emergency departments o Minimum Data Set (MDS): Long-term care setting o Outcomes and Assessment Information Set (OASIS): Home healthcare o Essential Medical Data Set (EMDS)- Emergency care setting

Data ownership

refers to the creation of business owners over specific data. The business owners are responsible to create business rules and definitions when collecting specific data to support patient care and business operations

Critical thinking

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

Data stewardship:

the evaluation of the data collection based on business need and strategy to ensure data meets the requirements of both patient care and organizational needs. Data stewardship and data ownership are closely connected.

Institute of Electrical and Electronics Engineers:

the leading developer of international standards that underpin many current telecommunications, IT and power generation products and services. IEEE currently has standards that allow providers and hospital to achieve interoperability between medical instrumentation system (including medical devices) and though used in multiple types of systems, it is most often used in acute-care settings.

Metadata management

the management and definition of what is considered metadata (data that describes other data). It is important to clearly define what metadata will be collected and why it is being collected

Data standardization and integration:

to document the location of data collection and ensure standardized formats of the data

National Council for Prescription Drug Programs:

widely adopted by pharmacies and payers for exchange of retail pharmacy payment information. NCPDP created multiple standards including a standardized data dictionary for pharmacy data, a standard for e-prescribing called SCRIPT. This standard communicates prescription information (including new prescriptions, refill requests, fill status notifications and cancellation notifications) between prescribers and pharmacies.

Creation of principles for data stewardship includes 4 categories:

•(1) individual's rights •(2) responsibilities of the data steward •(3) needed security safeguards and controls •(4) accountability, enforcement and remedies for data stewardship

Example of Data Steward

•A heart clinic may have a data steward that oversees imaging and EKGS in the clinic, who leads data quality initiatives to evaluate potential issues and risks and leads efforts to ensure the accuracy and integrity of the data. •Other responsibilities of the data steward is to establish P/P for the system they are responsible for.

Relational Database

•A relational database is an organized collection of related data. •Typically a relational database is set up in rows and columns •Relational databases are easy to build, use and query within the application. (Ex: table 6.2, pg. 162 shows the # of deficient health records by physicians)

Valued Stragtegic Asset

•A successful IG initiative must have support of the executives of the healthcare organizations and align directly to the organization's strategic plan. •Securing the support of C-Suite level, including, Chief Financial Officer, Chief Strategy Officer, Chief Medical and Information Officer, Chief Executive Officer is key ensuring the Information Governance initiative has appropriate resources to achieve the strategic goals.

Data Integrity & Ahima

•AHIMA recommends healthcare organizations institute P/P for the management of data integrity. •Some of the key elements to include in data integrity policies are related to documentation requirements: which include: o Identification of who can document in the health record and the scope of that documentation o Timeliness of documentation o Safeguards from changing and deleting documentation

AHIMA's Information Governance Adoption Model Competencies

•AHIMA's Information Governance Adoption Model consists of 10 competencies that were intended to assist healthcare organizations in applying appropriate IG concepts .•The adoption model allowed an organization to focus on those areas of IG that it deemed important.

AHIMA's Information Governance Principles

•Accountability- create authority over the IG process •Transparency: Written P/P describing creation, implementation and maintenance of IG program •Integrity: Assurances that the data generated maintains authenticity and reliability •Protection: Create protections to safeguard data and information from improper use and disclosure •Compliance: A process to ensure all information complies with appropriate laws, regulations, standards •Availability: Processes to ensure that information is available when needed •Retention: Processes for the proper retention of information based on requirements from regulations, accrediting organizations, and company policy •Disposition: processes for secure and appropriate disposition of information that is no longer needed based on regulations and organization's policy

Business Intelligence

•An effective IG initiative supports the information needed by a healthcare organization to make good decisions for the organization and its community .•One of the benefits of IG is the ability to support business intelligence. •Business Intelligence is what you can with what you know about your healthcare organization, your community, etc. For example, the ability to analyze the top trends in diagnoses in a healthcare organization will allow the organization to expand service lines or enhance patient outcomes in areas where needed

Indices

•An index is a report or list from a database that provides guidance, indication, or other references to the data contained in the database. (much like a book index) •An index serves as a guide or indicator to locate something within a database or other systems storing data making it easier to find the needed information in order to aggregate and analyze the data.

Data Gove..

•Data governance is sometimes confused with information governance .•Data governance manages the data placed into the various information systems used in healthcare. •Information governance manages the information output from those information system

object-oriented database

•An object-oriented database stores different types of data including images i.e. MRIs, X-rays, fetal monitoring strips), audio files, documents, videos as well as data elements •An object-oriented database stores two types of information about the object: 1. describes the data itself (audio clip, image, video) 2. describes the method of using the data •Using an object-oriented database for the storage of fetal heart monitors allows a healthcare provider to query the database as well as the actual image.

Object-oriented database

•Another benefit in using object-oriented databases for fetal monitor strips is the ability to produce a report on the data of the fetal heart monitor for retention and destruction of the images .•When using object-oriented databases, the data are provided with the additional ability to retrieve the file when the link to the image is selected.

Data Interchange Standards

•Data Interchange Standards are needed to support and create structure with data exchanges to sustain interoperability between healthcare organizations .•The goals of data interchange standards are to facilitate consistent, accurate and reproducible capture of clinical data. •Data standards also support the integrity of data and quality of data when being shared between organizations.

Data Mining

•Data mining is the extraction of data from a database or data warehouse •It is the process of sorting through large data sets to identify patterns and establish relationships between specific or discrete data to solve problems through data analysis. o Examples of discrete data: lab values, diagnosis codes

Data Strategy

•Data strategy should be a clear, concise method created to support proper collection and use of health care data within an organization that is approved by executive leadership. •A data strategy will clearly define 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 Warehousing

•Data warehousing is 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. •Data Warehouse is a single database that makes it easier to access data from multiple databases through one single query and reporting interface. A data warehouse allows for consolidation of data by pulling data from multiple systems into a single database that allows for ease in reporting and analysis of the information.

Enterprise Information Management

•Enterprise Information Management (EIM) is the set of functions created by a healthcare organization to plan, organize, and coordinate people, technology, and content needed to manage information for the purposes of data quality, patient safety, and ease of use •There should written EIM P/P to address the collaborative efforts used across the system to protect the organization's enterprise information assets

Data Information Exchange Data/ Sharing

•Ex. A CT scan is performed on a patient who is being referred to another healthcare organization or provider. The results of the CT scan can be shared electronically to the referred healthcare entity to prevent the patient from having the same test repeated. •This also improves communication between providers which ultimately improves patient care.

Data Mapping example

•Example: Mapping 2 different types of coding systems to show the equivalent codes •Example: the ICD-10 code of E10.11, type 1 diabetes mellitus with ketoacidosis can be mapped to SNOMED-CT 371055001, type 1 diabetes mellitus with ketoacidosis. This allows for comparison between 2 different coding systems based on one code.

Data Integrity & HIM

•HIM departments have great responsibility in assuring data integrity. There should be written policies and procedures to address the :•administrative documentation requirements •clinical documentation requirements •the entering of information into the EHR •correcting and amending the record .•timeframes for correcting the health record

HIM & Data Governance

•HIM professionals play a key role in the success of implementing information and data governance programs in organizations .•Their training provides them with an understanding of healthcare's clinical, financial, regulatory and technology environments, which allows them to lead the information governance within an organization and be the liaison between executive leadership and clinical leadership

Data Mapping......

•In data mapping, it is important to evaluate the source of the data and the relationship of the source data to data in other systems. •Evaluation of data is the relationship between the source data and target data in regards to how close or distant the data from the two systems are linked together •This process helps to ensure integrity of the data in all systems within the organization.

Data Mapping --

•Inaccurate data mapping can result in misinterpretation of data and inaccuracy of information stored and maintained in systems. •Ex: If the ICD-10-CM code for cholera was incorrectly mapped to the incorrect SNOMED CT code, data used and reported from the SNOMED system could show incorrect information regarding patients diagnosed with cholera, unspecified

Information governance (IG)

•Information governance is the process for ensuring that control and accountability for enterprise (organization-wide) data management is established throughout an organization •It focuses on how healthcare organizations create processes, policies, and procedures for keeping information that is relevant to patient care and healthcare operations •IG helps a healthcare organization to prioritize its investments and creates accountability for protecting and managing information

Information Governance

•Information has grown as an essential asset to the strategic and operational part of a healthcare organization. •Healthcare organizations have engaged in rigorous processes to protect unauthorized access, use, disclosure, modification and destruction of the surge of information now being governed.

Valued Strategic Asset

•Information should be treated as a valued strategic asset. •A valued strategic asset is a resource that is used in a way that will improve the healthcare organization now and in the future. •Examples: A healthcare organization may need information related to financial projections, cost of services, offering more services, etc.

Data Stewardship....

•Responsibilities of the data steward should be clearly defined to ensure the privacy and security of health information including requirements for their use and disclosures and ensuring access to what is needed by the data steward to perform their job responsibilities. •Data security safeguards should be established to define technical and nontechnical mechanisms are being used to protect the confidentiality, integrity and accessibility of PHI.

Role of Data Steward

•The data steward acts as a liaison between the users of the data or system and the information governance committee to create priorities, identify any issues and plans to resolve those issues .•Other titles for data stewards is data analyst or business analyst.

Data Mapping....

•The purpose of the data map should be established. •The purpose of the map should describe why it is needed, what it represents and how it will be used within the organization .•Ex: A data map is created to show the relationship of the types of ambulatory services, i.e. ED or ambulatory surgery and map them directly to ambulatory services

Data Integrity

•There are tools and system functionalities that are available to assist with the quality, completeness and timeliness of clinical documentation. •Unfortunately, there are times in which these tools and system functions have been shown to create issues with data integrity.