Chapter 4, Documentation for Statistical Reporting and Public Health

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

WONDER database is an integrated information and communication system for pubic health. Its purposes are twofold: 1. To promote information-driven decision making by place timely useful facts in the hands of public health practitioners and researchers. 2. To provide the general public with access to specific and detailed information from the CDC.

Internal and External users

a healthcare facility users of secondary data sources. External users include the CDC, NCHS, and NCVHS also the federal government which collects data from the states on vital events such as births and deaths.

PHYSICIAN INDEX

categories patients by primary physician. It guides the retrieval of cases treated by a particular physician. This index is created simply by sorting patients by physician. Information required in a physician index includes the physician's name or code, health record number, diagnosis, operations, disposition of the patients the physician treated, dates of admission and discharged, and gender and age of patients.

RESEARCH

data contained in the health record are required for: research, statistical reporting, cancel registries, trauma registries, burn registries, disease registries, implant registries, and birth certificate registration, to name a few public health uses.

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS (NCHS)

formed in 1949, helps connect the interests of the US government, the health industry, and research and public health entities and helps connect to those working on health information policy in other countries. Mission of the NCVHS is to advise the federal government on the information needs underlying health policy. It designs and coordinates improvements in national and international vital and health statistics.

REGISTRY

is a chronological listing of patients with a common characteristic. Commonly maintained by healthcare facilities are listed in Figure 4.1 page Creation and maintenance of these registries often a responsibility of the HIM department. Contain more extensive information than index. Registry maintenance consists of the following activities: -case definition -case finding -case abstracting

MASTER PATIENT INDEX (MPI)

is a database of patients within a facility or associated group of facilities (enterprises). It is in paper or electronic format, may be considered the most important resource in a healthcare facility because it tracks patient activity across every type of care setting. Identifies all patients who have bee treated in a facility or enterprise and lists the health records or identification numbers associated with the names.

CLINICAL TRIAL

is an investigation of the safety and effectiveness of new treatments and tests.

AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI)

is one example of a standards development organization (SDO) and coordinates the development of voluntary standards in many industries, including healthcare and most in the U.S. are member of ANSI.

National Health Care Survey

is one of the major national public health surveys. It relies on data from patients' health records and includes information on several practice areas.

Health record documentation

is the source data for statistical reports that guide decisions in local facilities and these decisions can influence the health of a state and even a nation.

Health DATA SETS have 2 purposes

1. To identify data elements that should be collected for each patient 2. To provide uniform definitions for common terms

Data Quality Issues

Indexes, registries, and databases are only helpful when the data they contain are accurate. Incorrect data will likely result in serious errors in decision making.

FOOD AND DRUG ADMINISTRATION (FDA)

Modernization Act of 1997 mandated the development of a clinical trials database, which enables patients and practitioners to determine which clinical trials are available and applicable.

Healthcare Information Technology Standards Panel (HITSP)

administered by ANSI, is a partnership between the private and public for sharing information among organizations and system.

DATA DICTIONARY

all data elements included in the database or registry must be defined in, and the HIM professional may oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry.

DISEASE and OPERATION INDEXES

allow the retrieval of patient information by diagnosis or surgical procedure and arranged by diagnostic or procedure codes, facilitating the study of patients with the same or similar conditions or treatment. This sorting guides the locating of health records to conduct quality improvement and research studies or to monitor quality of care. Also useful for retrieving records for research studies. The following data elements from the health record are essential for this index: page

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)

an agency within HHS, aims to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans.

Aggregate statistical data

are also useful for clinical and administrative decision support.

CONSOLIDATED HEALTH INFORMATICS (CHI) INITIATIVES and OFFICE OF THE NATIONAL COORDINATOR OF HEALTH INFORMATION TECHNOLOGY (ONC)

are federal initiatives that speak to the importance of healthcare information stands. NCVHS put forward a vision for a national health information infrastructure in 2001 report Information for Health, which was followed in 2002 by its vision for 21st century health statistics.

Public-use data files

are sorted by individual provider type, organizations, federal agencies, state agencies and health plans.

INDEXES

are used to sort data to assist with the study of certain data elements.

Data Council

assists in decision making, analysis, and dissemination of information within HHS as well as to public- and private-sector entities with common data interests. Addition, HHS is a national leader in health and human services information policy including national data standards, privacy policy, and national health information infrastructure issues.

Index

can be maintained manually or as part of a computerized system, retention of entries depends on the MPI's use.

CENSUS

collection and calculation of various healthcare statistics also depend on the health record. Statistics including ratio and percentages (for example, percentage of occupancy, and death and autopsy rates; hospital census reports) are needed to describe the operation types of statistics automatically.

NATIONAL CENTER FOR HEALTH STATISTICS (NCHS)

complies statistical information to guide actions and policies to improve health. NCHS uses health statistics to: Page Collaborates with the health community and uses a variety of approaches to obtain of information. Also monitors the national public health infrastructure and provides information to identify and address critical health problems.

Omnibus Budget Reconciliation Act of 1990, Public Law 101-508

congress amended this law, to include "any negativity action or finding by such authority, organization, entity regarding the practitioner or entity."

NCVHS

convened its four subcommittees (population health, standards, quality, and privacy/confidentiality/security) to develop a conceptual paper, titled Toward Enhanced Information Capacities for Health.

PRIMARY or AGGREGATE DATA

data are categorized as either, the health record consists entirely of PATIENT-SPECIFIC/IDENTIFIABLE DATA or primary data.

DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

established its Data Council to coordinate and integrate its data collection and analysis activities. It has taken steps to address key data needs, promote a coordinated organization-wide strategy on data issues, and strengthen collaboration with private-sector entities, state and local governments, and other partners. Also Data Council supports HHS-wide implementation of HIPPA Administrative Simplification, an initiative to adopt national standards for electronic healthcare transactions.

PROTOCOL

the trial proceeds according to, which is the list of rules and procedures to be followed.

CDC WONDER

furthers the CDC's mission of health promotion and disease prevention by expediting and simplify access to public health information for state and local health departments, the US Public Health Service, and the academic public health community.

INCIDENCE and PREVALENCE

health record documentation is required to develop the databases used by public health departments to provide information on the incidence and prevalence of the diseases, possible high-risk populations, survival statistics, and trends overtime.

Under the leadership of NCHS and NCVHS

in collaboration with other organizations data sets were developed for a variety of health settings, first of which were acute care, long-term care, and ambulatory care.

VITAL STATISTICS

include data on births, deaths, fetal deaths, marriages, and divorce. Responsibility for the collection of vital statistics rests with the states, which serve as the official repository for birth and death certificates and share information with the NCHS.

Aggregate data (SECONDARY DATA)

includes complied information on groups of people or patients that does not identify any particular patient.

HEALTH SERVICES RESEARCH

one of its functions is to support and in 2010, AHRQ and CMS published a handbook to heal providers set up registries. The handbook included recommendations for design and data source access and suggestions on ways to encourage participation in registries.

Continued efforts from subcommittees will focus on these 3 areas:

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Data elements included in the MPI should:

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SECONDARY DATA SOURCE

provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes. Also quickly demonstrate survival rates t different stages of diseases.

National Practitioner Data Bank (NPDB)

provides a database of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medial staff privileges) taken by healthcare entities such as hospitals against physicians, dentists other healthcare providers, private accrediting organizations, and peer review organizations. Provides a data specific to an individual healthcare practitioner for these purposes. This is part helpful to healthcare facilities when a healthcare practitioner has lost his license to practice in one state and overs to another state to practice. Also includes a public-use data file that does not include healthcare practitioner-specific information. These data are used for statistical analysis and one from Medical Malpractice Payment reports, Adverse Action Reports, and Medicare and Medicaid exclusion actions.

DATABASE

provides information on facility-specific, state, and national indexes, registries.

External users

such as third-party payers, government agencies, and accreditation organization, intensified the use of health information and created demands for standards that promote interoperable electronic interchange of data and information.

clinical trials

the National Library of Medicine has developed the database, for use by both consumers and practitioners. Information in the database includes the following: Page

PUBLIC HEALTH

the health of populations in geopolitical locations is the domain. One of the duties of public health agencies is surveillance of the health status of the population within their jurisdictions.

PRIMARY DATA SOURCE

the health record is considered because it contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient.

ENTERPRISE MASTER PATIENT INDEX (EMPI)

the need of identify patients across departments within a facility has lead to the development and consolidates information fro registration, scheduling, financial, and clinical software systems. Also may assist organization in maintain HIPPA patient identification and tracking requirements as listed.

HEALTHCARE INFORMATION STANDARDS

the original data sets developed to support uniform data collection are inadequate for an electronic environment, and may public and private organizations have been actively engaged in the process of developing to support EHR development and information exchange.

Main trend in collecting secondary data

to be the increases use of automated data entry. Registries and databases commonly use data already available in electronic form rather than manually abstract all data.

Primary purpose of healthcare documentation is

to chronicle patients' health overtime. This benefits consumers by ensuring the continuity of their care, the information complied from healthcare documentation can also reveal tends and contribute to improvement healthcare for consumers of all ages.

FACILITY-SPECIFIC and POPULATION-BASED REGISTRY

to reveal patterns, data must be extracted from individual records and entered into databases. These data maybe used in or population-based registry for research improvement in customer care. Addition, they may be reported to the state and become part of state and federal databases used to inform health policy and improve healthcare.

The use of EHRs w

will take separate databases for various diseases and conditions unnecessary. The patient health record itself will be a database that can be queried for information currently obtained from specialized registries.