Chapter 2 - 5340

AHIMA Data Dictionary

"a descriptive list of names (also called 'representations' or 'displays'), definitions, and attributes of data elements to be collected in an information system or database"

Two main sources of missing EHR Data:

1. Data were not collected 2. Documentation was not complete

Data Definition

Clear definitions of data elements must be provided so that current and future data users will understand what the data mean. The specific meaning of a healthcare-related data element

Data Accuracy

Data that reflect correct, valid values are accurate.

ICD-10-PCS (Procedure Coding System)

ICD-10-PCS was developed by CMS for US inpatient hospital settings only.

Point of care (POC) health gap analytics.

Identifying patient-specific health care gaps and issuing a specific set of actionable recommendations and notifications either to physicians at the point of care or to patients via a patient portal or PHR

Population Health & Patient Records

Information from patient records is used to monitor population health, assess health status, measure utilization of services, track quality outcomes, and evaluate adherence to evidence-based practice guidelines.

Billing and Reimbursement & Patient Records

Patient records provide the documentation patients and payers use to verify billed services.

Office of Inspector General of the Department of Health and Human Services (HHS OIG)

Publishes compliance guidelines to facilitate health care organizations' adherence to ethical and legal coding practices. The OIG is responsible for (among other duties) investigating fraud involving government health insurance programs.

Episode of Care

Services provided to a patient with a specific condition for a specific period of time.

Diagnosis-related groups (DRGs)

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay DRGs are in turn the basis for determining appropriate inpatient reimbursements for Medicare, Medicaid, and many other health care insurance beneficiaries.

837P

The 837P (Professional) is the standard file format used by health care professionals and suppliers to transmit health care claims electronic

ICD-10 (International Classification of Diseases)

The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. This includes providing a format for reporting causes of death on the death certificate.

Data Currency

The extent to which data are up-to-date; a datum value is up-to-date if it is current for a specific point in time, and it is outdated if it was current at a preceding time but incorrect at a later time

Data Consistency

The extent to which the healthcare data are reliable, identical, and reproducible by different users across applications

The National Center of Health Statistics (NVHS)

The federal agency responsible for publishing ICD-10-CM (Clinical Modification) in the United States.

History's and Physical

The history component of the report describes any major illnesses and surgeries the patient has had, any significant family history of disease, patient health habits, and current medications. The physical component of this report states what the physician found when he or she performed a hands-on examination of the patient. The history and physical together document the initial assessment of the patient for the particular care episode and provide the basis for diagnosis and subsequent treatment

Identification Screen

The identification data generally includes at least the patient's name, address, telephone number, insurance carrier, and policy number, as well as the patient's diagnoses and disposition at discharge.

Imaging and X-ray Reports

The radiologist is responsible for interpreting images produced through X-rays, mammograms, ultrasounds, scans, and the like and for documenting his or her interpretations or findings in the patient's record. These findings should be documented in a timely manner so they are available to the appropriate provider to facilitate the appropriate treatment.

CPT (Current Procedural Terminology)

The standardized classification system for reporting medical procedures and services-- Published by the American Medical Association

Data timeliness

Timeliness is a critical dimension in the quality of many types of health care data. -- critical lab values The availability of up-to-date data within the useful, operative, or indicated time

Population Health

To improve health outcomes within defined communities (Stoto, 2013). Population health focuses on maintaining health and managing health care utilization for a defined population of patients or community with the goal of decreasing costs.

Weiskopf and Weng Completeness Dimension encompasses:

- Accessibility - Accuracy - Availability - Missingness - Omission - Presence - Quality - Rate of recording - Sensitivity - Validity

Weiskopf and Weng Plausibility Dimension encompasses:

- Accuracy - Believability - Trustworthiness - Validity

Weiskopf and Weng Correctness Dimension encompasses:

- Accuracy - Correction made - Errors - Misleading - Positive predictive value - Quality - Validity

Weiskopf and Weng Concordance Dimension encompasses:

- Agreement - Consistency - Reliability - Variation

Weiskopf and Weng 5 Data Quality Dimensions

- Completeness: Is the truth about a patient present? - Correctness: Is an element that is in the EHR true? - Concordance: Is there agreement between elements in the EHR or between the EHR and another data source? - Plausibility: Does an element in the EHR make sense in light of other knowledge about what that element is measure? - Currency: Is an element in the EHR a relevant representation of the patient state at a given point in time?

Basic Requirements of Health Care data analysis

- First, there must be a source of data, - Second, these data must be stored in a retrievable manner, - Third an analytical tool, such as mathematical statistics, probability models, predictive models, and so on, must be applied to the stored data. - Fourth, to be meaningful, the analyzed data must be reported in a usable manner.

Two major coding systems are employed by health care provider today:

- ICD-10 (International Classification of Diseases) - CPT (Current Procedural Terminology)

Common Components of patient records (not comprehensive)

- Identification screen - Problem list - Medication records - History and physical - Progress notes - Consultation - Physician's orders - Imaging and X-ray reports - Laboratory reports - Consent and authorization forms - Operative report - Pathology report - Discharge Summary

Deloitte 5 areas of analysis crucial in the emerging era of providers being more accountable

- Population management analytics - Provider profiling/physician performance analytics - Point of care (POC) health gap analytics - Disease management - Cost modeling/ performance risk management/ comparative effectiveness.

Weiskopf and Weng Currency Dimension encompasses:

- Recency - Timeliness

Data Quality programs should include automated and human strategies:

- Standardizing data entry fields and processes for entering data - Instituting real-time quality checking, including the use of validation and feedback loops - Designing data elements to avoid errors (e.g., using check digits, algorithms, and well-designed user interfaces) - Developing and adhering to guidelines for documenting the care that was provided - Building human capacity, including training, awareness-building, and organizational change

Two primary types of data error

- Systematic Errors: errors that can be attributed to a flaw or discrepancy in the system or in adherence to standard operating procedures or systems. - Random Errors: caused by carelessness, human error, or simply making a mistake.

Two basic types of data Contained in EHR & How they should be valued.

- structured data that is quantifiable or predefined - unstructured data that is narrative. To effectively use EHR data to create new knowledge, either through analytics or research, will require HIT leaders to adopt the more stringent data quality criteria posed by these uses.

The most commonly recognized purposes for creating and maintain patient records:

1. Patient Care 2. Communication 3. Legal documentation 4. Billing and reimbursement 5. Research and quality management 6. Population Health 7. Public Health

Healthcare Common Procedure Coding System (HCPCS)

A collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs

Consultation

A consultation note or report records opinions about the patient's condition made by another health care provider at the request of the attending physician or primary care provider.

Electronic Medical Records (EMR)

A digital version of the paper charts. An EMR contains the medical and treatment history of the patients in one practice (or organization). EMR's allow for: - Tracking data over time - Easily identify which patients are due for preventive screenings or checkups - Check how their patients are doing on certain parameters such as blood pressure readings or vaccinations - Monitor and improve the overall quality of care within the practice

Comprehensive Shared Care Plan (CSCP) Key Goals

A tool that supports person-centered care by multidisciplinary team that relies on HIT to enable collaboration across settings. - It should enable a clinician to electronically view information that is directly relevant to his or her role in the care of the person, to easily identify which clinician is doing what, and to update other members of an interdisciplinary team on new developments. - It should put the person's goals (captured in his or her own words) at the center of decision making and give that individual direct access to his or her information in the CSCP. - It should be holistic and describe clinical and nonclinical (including home- and community-based) needs and services. - It should follow the person through high-need episodes (e.g., acute illness) as well as periods of health improvement and maintenance (Baker et al., 2016).

Accountable Care Act (ACA)

Accountable Care Act (ACA) and other health care payment reform measures, organizations and communities have begun to shift focus from episodic care to population health.

Data comprehensiveness

All of the data required for a particular use must be present and available to the user. Even relevant data may not be useful when they are incomplete.

Protected Health Information (PHI)

Any information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.

Diagnostic and procedural codes

Captured during the patient encounter, not only to track clinical progress but also for billing, reimbursement, and other administrative purposes. This diagnostic and procedural information is initially captured in narrative form through physicians' and other health care providers' documentation in the patient record.

ICD-10-CM (Clinical Modification)

Coding plays a major role in reimbursement to hospitals and other health care institutions. ICD-10-CM codes used for determining the diagnosis-related group (DRG).

Continuum of care

Continuum of care, as defined by HIMSS (2014), is a concept involving a system that guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care.

Consent and authorization forms

Copies of consents to admission, treatment, surgery, and release of information are an important component of the patient record related to its use as a legal document.

Health care data quality

Crosby (1979) defines quality as "conformance to requirements" or conformance to standards. Juran (Juran & Gryna, 1988) defines quality as "fitness for use," products or services must be free of deficiencies. What these definitions have in common is that the criteria against which quality is measured will change depending on the product, service, or use.

Data granularity

Data granularity is sometimes referred to as data atomicity. That is, individual data elements are "atomic" in the sense that they cannot be further subdivided. The level of detail at which the attributes and characteristics of data quality in healthcare data are defined Values for data should be defined at the correct level for their use.

Data Accessibility

Data items that are easily obtainable and legal to access with strong protections and controls built into the process. Data that are not available to the decision makers needing them are of no value to those decision makers.

Data Relevancy

Data must be relevant to the purpose for which they are collected. The extent to which healthcare-related data are useful for the purposes for which they were collected

Disease Management

Defining best practice care protocols over multiple care settings, enhancing the coordination of care, and monitoring and improving adherence to best practice care protocols

Data warehouse

Differs from a database in its structure and function In health care, data warehouses that are derived from health care information systems may be referred to as clinical data repositories. The data in a data warehouse come from a variety of sources, such as the EHR, claims data, and ancillary health care information systems (laboratory, radiology, etc.).

Electronic Health Records (EHRs)

Do all those things EMRs do—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider's office (or during episodes of care)—and is inclusive of a broader view on a patient's care.

Legal health record (LHR)

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information --- legal documentation of the care provided to the patients.

Public Health & Patient Records

Federal and state public health agencies use information from patient records to inform policies and procedures to ensure that they protect citizens from unhealthy conditions.

Database

Generally refers to any structured, accessible set of data stored electronically; it can be large or small. (i.e.) The backend of EHR and claims systems [large databases]

Figure 2.1 Health care data to health care knowledge hierarchy

Health Care Knowledge Health Care Information Health Care Data

Basic Health Care Statistics

Health statistics are numbers that summarize information related to health. Researchers and experts from government, private, and non-profit agencies and organizations collect health statistics. They use the statistics to learn about public health and health care The number of descriptive health care statistics that can be produced is limitless. Two categories of statistics directly related to inpatient stays are routinely captured and reported: - Census Statistics: These data reveal the number of patients present at any one time in a facility. Several commonly computed rates are based on these census data, including the average daily census and bed occupancy rates. - Discharge Statistics: This group of statistics is calculated from data accumulated when patients are discharged. Some commonly computed rates based on discharge statistics are the average length of stay, death rates, autopsy rates, infection rates, and consultation rates.

Knowledge

Is seen by some as the highest level in a hierarchy with data at the bottom and information in the middle "a combination of rules, relationships, ideas, and experience." Another way of thinking about knowledge is that it is information applied to rules, experiences, and relationships with the result that it can be used for decision making.

Clinical example of raw data:

Lab value, hematocrit (HCT) = 32, or a diagnosis such as diabetes. These are singular facts, data at the most granular level --- They take on meaning when assigned to particular patients in the context of their health care status or analyzed as components of population studies.

Laboratory Reports

Laboratory reports contain the results of tests conducted on body fluids, cells, and tissues. labs. Lab personnel are responsible for documenting the lab results into the patient record.

Cost modeling/performance risk management/comparative effectiveness.

Managing aggregated costs and performance risk and integrating clinical information and clinical quality measures

Provider profiling/physician performance analytics.

Normalizing (severity and case-mix-adjusted profiling), evaluating, and reporting the performance of individual providers (PCPs and specialists) compared to established measures and goals

Medical Record & Health Record

Often used interchangeably to describe a patient's clinical record. The Office of the National Coordinator for Health Information Technology (ONC) distinguishes the electronic medical record and the electronic health record

Operative report

Operative reports describe any surgery performed and list the names of surgeons and assistants. The surgeon is responsible for documenting the information found in the operative report.

Disease and Procedure Indexes

Originally large card catalogues or books that kept track of the numbers of diseases treated and procedures occurring in a facility by disease and procedure codes. Now that repositories of health care data are common, the disease and procedure index function is generally handled as a component of the EHR. The retrieval of information related to diseases and procedures is still based on ICD and CPT codes, but the queries are limitless.

Personal Health Record (PHR)

PHR "is a tool . . . to collect, track and share past and current information about your health or the health of someone in your care."

Pathology report

Pathology reports describe tissue removed during any surgical procedure and the diagnosis based on examination of that tissue. The pathologist is responsible for documenting the information contained within the pathology report.

2. Communication & Patient Records

Patient records are an important means by which physicians, nurses, and others, whether within a single organization or across organizations, can communicate with one another about patient needs.

Research and Quality management & Patient Records

Patient records are used in many facilities for research purposes and for monitoring the quality of care provided. Patient records can serve as source documents from which information about certain diseases or procedures can be taken

Patient Care & Patient Records

Patient records provide the documented basis for planning patient care and treatment, for a single episode of care and across the care continuum.

Legal Documentation & Patient Records

Patient records, because they describe and document care and treatment, are also legal records. In the event of a lawsuit or other legal action involving patient care, the record becomes the primary evidence for what actually took place during the care.

Physician's orders

Physician's orders are a physician's directions, instructions, or prescriptions given to other members of the health care team regarding the patient's medications, tests, diets, treatments, and so forth.

Data Precision

Precision often relates to numerical data. Precision denotes how close to actual size, weight, or another standard a particular measurement is. The degree to which measures support their purpose, and/or the closeness of two or more measures to each other

Problem list

Problem list, which identifies significant illnesses and operations the patient has experienced. This list is generally maintained over time.

Health Care Information

Processed health data. (Processed - formal analysis to explanations supplied by the individual decision maker's brain) HIPPA Classification of Health Information any information oral or recorded in any form that does the following: - Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse - Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual

Population management analytics

Producing a variety of clinical indicator and quality measure dashboards and reports to help improve the health of a whole community, as well as help identify and manage at-risk populations

Progress Notes

Progress notes are made by the physicians, nurses, therapists, social workers, and other staff members caring for the patient. Each provider is responsible for the content of his or her notes. Progress notes should reflect the patient's response to treatment along with the provider's observations and plans for continued treatment. Commonly used format SOAP - Subjective findings - Objective findings - Assessment - Plan

Health Care Data

Raw health care facts, generally stored as characters. words, symbols, measurements, or statistics - Not very useful for decision making i.e. 79% *But what does the 79% represent?

Small Data in Health Care

Small data is data in a volume and format that makes it accessible, informative and actionable

CMS-1500

Standard claim form used for outpatient reimbursement (overseen and developed by NUCC) the electronic counterpart is 837P similar to UB-04 and 837I for institutional care, it has become the de facto standard for all types of noninstitutional provider claims, such as those for private physician services.

American Hospital Association

The American Hospital Association (AHA) is the national organization that represents and serves all types of hospitals, health care networks, and their patients and communities. Nearly 5,000 hospitals, health care systems, networks, other providers of care and 43,000 individual members come together to form the AHA. American Hospital Association (AHA) formed the National Uniform Billing Committee (NUBC), bringing the major national provider and payer organizations together for the purpose of developing a single billing form and standard data set that could be used for processing health care claims by institutions nationwide.

National Uniform Billing Committee (NUBC)

The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated through the offices of the American Hospital Association (AHA) and includes participation of all the major national provider and payer organizations. The committee was originally formed to develop a single standard billing format and data set to be used nationwide by institutional providers and payers for handling health care claims. Today, the Committee monitors and manages the utilization of this standard uniform (UB) billing form and data set used throughout the industry for billing transactions. The NUBC is responsible for maintaining and updating the specifications for the data elements and codes that are used for the UB-04/CMS-1450 and 837I.

Discharge Summary

The discharge summary summarizes the hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, responses to treatments, condition at discharge, and instructions for medications, activity, diet, and follow-up care.

AHIMA - Data quality characteristics

They define data quality management as "the business processes that ensure the integrity of an organization's data during collection, application (including aggregation), warehousing, and analysis" (Davoudi et al., 2015). These characteristics are to be measured for conformance during the entire data management process: - Data accuracy - Data accessibility - Data Comprehensiveness - Data Consistency - Data Currency - Data Definition - Data granularity - Data Precision - Data relevancy - Data timeliness

Medication Record (Medication administration record MAR)

This record lists medicines prescribed for and subsequently administered to the patient. It often also lists any medication allergies the patient may have.

Big Data

a broad term for datasets so large or complex that traditional data processing applications are inadequate. the huge and complex data sets generated by today's sophisticated information generation, collection, storage, and analysis technologies Composed of 3 V's: - Very large volume of data - A variety (e.g., images, text, discrete) of types and sources (EHR, wearable fitness technology, social media, etc.) of data - A variety (e.g., images, text, discrete) of types and sources (EHR, wearable fitness technology, social media, etc.) of data

National Uniform Claim Committee (NUCC)

created by the American Medical Association (AMA) to develop a standardized data set for the noninstitutional or "professional" health care community to use in the submission of claims (much as the NUBC has done for institutional providers).