Chapter 7 - Secondary Data Sources
one of the major national public health surveys is the ____ - to a large extent, it relies on data from patients' health records ___ consists of a number of parts, including - National Hospital Care Survey - National Hospital Ambulatory Medical Care Survey - National Survey of Long-Term Care Providers data in the ____ is information on the utilization of healthcare provided in inpatient settings, EDs, and OP departments - survey collects data from a nationally representative sample of entities and aims to provide hospital utilization statistics for the nation
National Health Care Survey
the ____ is used to monitor the health status of civilian, non-institutionalized population of the US data are collected through personal household interviews - interviews from the US Census Bureau visit American homes to ask about a broad range of health topics
National Health Interview Survey
data for the ____ are collected on a representative sample of hospital-based and freestanding ambulatory surgery centers data include - patient demographic characteristics - source of payment - anesthesia given - diagnoses - surgical and nonsurgical procedures on patient visits
National Hospital Ambulatory Medical Care Survey
the National Immunization Program at the CDC has worked with the National Vaccine Advisory Committee (NVAC) to develop a core set of immunization registries these data elements include - patient name (first, middle, and last) - patient birth date - patient gender - patient race - patient ethnicity - patient birth order - patient birth state and country - mother's name (first, middle, last, and maiden) - vaccine product - vaccine manufacturer - vaccine lot number other elements may be included as needed by the individual registry
data collection for immunization registries
ACS certifies levels 1, 2, 3, 4, and 5 trauma centers - as part of the requirements, ACS states that level 1 trauma centers must have a trauma registry as part of certification requirements, the ACS states that the level 1 trauma center, the type of center receiving the most serious cases and providing the highest level of trauma service, must have a trauma registry
Trauma Center Levels: Level 1 - Able to provide total care for every aspect of injury from prevention through rehabilitation Level 2 - Able to initiate definitive care for all injured patients Level 3 - Able to provide prompt assessment, resuscitation, surgery intensive care and stabilization of injured patients, and emergency operations Level 4 - Able to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher-level trauma center; provides evaluation, stabilization, and diagnostic capabilities for injured patients Level 5 - Able to provide initial evaluation, stabilization, and diagnostic capabilities, and prepares patients for transfer to higher levels of care
True or false: HIM supervisors and managers are internal users of secondary data.
True
True or false: Secondary data may be used to improve the health of an entire human population.
True
the ____, developed by NLM, provides a way to integrate biomedical concepts from a variety of sources to show their relationships this process allows links to be made between different information systems for purposes such as the EHR ___ is of particular interest of the HIM manager because of medical vocabularies such as ICD-10-CM, CPT, and Healthcare Common Procedure Coding System (HCPCS)
Unified Medical Language System (UMLS)
The healthcare organization would like to get approval for their cancer program. They should contact the: a. American College of Surgeon's Commission on Cancer b. Centers for Disease Control and Prevention c. North American Association of Central Cancer Registries d. National Committee on Vital Health Statistics
a. American College of Surgeon's Commission on Cancer
the case definition for the trauma registry varies, but frequently involves inclusion of cases with diagnoses from the trauma diagnosis codes in ICD-10-CM to find cases with trauma diagnoses, the trauma registrar can access the disease indexes looking for cases with codes from this section of ICD-10-CM - the trauma registrar may also look at deaths in services with frequent trauma diagnosis (trauma, neurosurgery, orthopedics, plastic surgery) to find additional cases
case definition and case finding for trauma registries
after the cases to be included have been determined, the next step is usually ____ ___ is a method used to identify the patients who have been seen or treated in the healthcare organization for the specific disease or condition of interest to the registry - after cases have been identified, extensive information is abstracted from the patients' health records into the registry database or extracted from other databases and automatically entered into the registry database
case finding
traditionally, cancer registrars have been trained through on-the-job training and professional workshops and seminars the National Cancer Registrars Association (NCRA) has worked with colleges to develop formal educational programs for cancer registrars - a cancer registrar may become credentialed as a _____ by passing an examination provided by the National Board for Certification of Registrars (NBCR) - eligibility requirements for the certification exam include a combination of experience and education
certified tumor registrar (CTR)
in addition to demographic information about the cases, other data collected may include laboratory values such as glycated hemoglobin, also known as HbA1C - test is used to determine the patient's blood glucose for a period of approximately 60 days prior to the time of the test facility registries may tack patient visits to follow up with patients who have not been seen in the past year
data collection for diabetics registries
at the national level, the ____ has responsibility for these databases the ____ provides statistical, accurate, relevant, and timely data that help guide actions and policies to improve the health of the American people - this information or data obtained may be gathered through surveys
National Center for Health Statistics (NCHS) National, State, and County Public Health Databases
because of bioterrorism scares, the CDC developed the ____ that serves as a major part of the Public Heath Information Network (PHIN) - system provides a national surveillance system by connecting the CDC to monitor trends from disease reporting at the local and state levels to look for possible bioterrorism incidents
National Electronic Disease Surveillance System (NEDSS)
demographic data on patients receiving implants are included in the registry the FDA requires that all reportable events involving medical devices include: - user facility report number, name and address of the device manufacturer, device brand name and common name, produce model, catalog, serial, and lot numbers, brief description of the event reported to the manufacturer or the FDA, whether the report was submitted (thus, these data items should be included in the implant registry to facilitate reporting)
data collection for implant registries
a ____ is a descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database
data dictionary
according to the National Cancer Registries Association (NCRA), the first hospital cancer registry was founded in 1926 at Yale-New Haven Hospital It has long been recognized that information is needed to improve the diagnosis and treatment of cancer - cancer registries were developed as an organized method to collect these data (facility based collection - within a hospital or clinic population based collection - more than one healthcare organization within a state or region)
development of cancer registries
____ include cases of patients with diabetes for the purpose of assistance in managing care as well as for research - patients whose diabetes is not kept under control frequently have numerous complications the ____ can keep up with whether the patient has been seen by a physician to prevent complications
diabetes registries
____ of patient data are individuals and institutions outside the healthcare organization ex: data banks, federal agencies States have laws mandating that cases of patients with diseases such as TB, STDs, and other communicable diseases be reported to the state department - the federal government collects data from the states on vital events such as births and deaths secondary data provided to ____ are generally aggregate data, not patient-identifiable data. Thus, the data can be used as needed without risking breaches of confidentiality
external users
_____ include cancer cases from a particular type of healthcare organization such as a hospital or clinic the data from ____ are used to provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment the data may provide comparisons in survival rates and quality of life for patients with different treatments and at different stages of cancer at the time of diagnosis
facility-based registries
in a facility-based cancer registry, data are initially reviewed and collected from the patient's health record in addition to demographic information, data in the registry about the patient include the following:
- type and site of the cancer - diagnostic methodologies - treatment methodologies - stage at the time of diagnosis (stage provides information on the size and extent of the spread of the tumor throughout the body)
Four major purposes for collecting secondary data
1. Quality, performance, patient safety. - ex: HCOs collect core measure information from the health record for CMS to evaluate the quality of care within the HCO 2. Research. - data taken from health records and entered into databases help researchers determine the effectiveness of alternate treatment methods. - ex: a disease database that cross-references an index of human diseases, medications, signs, abnormal findings, etc. - ex: data collected from PCORI used to help patients, families, and clinicians make better healthcare decisions 3. Population Health. - an "interdisciplinary, customized approach that allows health departments to connect practice to policy for change to happen locally" - ex: states require information reported to them on certain diseases so the extent of the disease can be determined, and steps taken to prevent the spread of that disease 4. Administrative. - in credentialing physicians, HCOs are required to access a national database for information on previous malpractice or other adverse decisions against a physician. This information is used to evaluate the qualifications, skills, and performance history of a physician
the ____ has an approval process for cancer programs one of the requirements of this process is the existence of a cancer registry as part of the program - the ____ standards are published in the Cancer Program Standards - when the ____ surveys the cancer program, part of the survey process is a review of cancer registry activities
American College of Surgeons (ACS) Commission on Cancer
the _____ provided funding for a national program of cancer registries with population-based registries in each state according to the law, these registries were mandated to collect data such as: - Demographic data about each case of cancer; demographic data describing the individual including the patient's name, age, gender, race, ethnicity, and birthplace - information on the industrial or occupational history of the individuals with the cancers (to the extent such information is available from the same health record) - administrative information, including date of diagnosis and source of information - pathological data characterizing the cancer, including site, stage of neoplasm (specifies the amount of metastasis, if any), incidence, and type of treatment
Cancer Registries Amendment Act of 1992
case definition = deciding which cases should be entered in the registry - ex: in a cancer registry, all cancer cases except skin cancer might meet the definition for the cases to be included information of malignant neoplasms, data on benign and borderline brain or CNS tumors must be collected by the National Program of Cancer Registries In the facility-based cancer registry, the first step is case finding - one way to find cases is through the discharge process in HIM department - during the discharge procedure, coders or discharge analysts can easily earmark cases of patients with cancer for inclusion in the registry -the facility-specific disease indexes can be used to identify patients with diagnoses of cancer - additional methods include reviews of pathology reports and lists of patients receiving radiation therapy or other cancer treatments to determine cases that have not been found by other methods population-based registries - usually depend on hospitals, physician officers, radiation facilities, ASCs, and pathology laboratories to identify and report cases to the central registry (administrators of a population-based registry have a responsibility to ensure all cases of can
Case definition and Case Finding in Cancer Registries
the ____ also has national standards regarding the completeness, timeliness, and quality of cancer registry data from state registries through the National Program of Cancer Registries (NPCR) the NPCR was developed as a result of the Cancer Registries Amendment of 1992 - ____ collected data from the NPCR state registries
Centers for Disease Control and Prevention (CDC)
there are currently several cancer staging systems American Joint Committee on Cancer (AJCC) - worked through its Collaborative Stage Task Force with order organizations and staging systems to develop a new standardized staging system - the _____ the ____ staging system uses computer algorithms to describe how far a cancer has spread after the initial information is collected at the patient's first encounter, data in the registry are updated periodically though the follow-up process frequently, the population-based registry only collects information when the patient is diagnosed - sometimes, it receives follow-up information from its local, state, or national entities (these entities usually submit information to the central registry electronically)
Collaborative Stage Data Set
True or false: A patient health record contains aggregate data.
False
after the cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database data elements collected in the abstracting process vary among registries abstracting can be either the process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome, or extracting elements of data from a source document or database and entering them into an automated system data elements in the abstracting process include: - demographic information on the patient - information on the injury - care the patient received before hospitalization (such as care at another transferring hospital or car from an EMT who provided care at the scene of a crash or in transport from the crash site to the hospital) - status of the patient at the time of admission - patient's course in the hospital - diagnosis and procedure codes - Abbreviated Injury Scale - Injury Severity Scale
Data collection for Trauma Registries
the type of information collected varies according to the type of registry pretransplant data about the recipient include - demographic data - patient's diangosis - patient's status cods regarding medical urgency - patient's functional status - whether the patient is on life support - previous transplantations - histocompatibility (compatibility of donor and recipient tissues) information on donors varies according to whether the donor is living. For organs harvested from patients who have died, information collected include: - cause and circumstances of the death - organ procurement and consent process - medications the donor was taking - other donor history for a living donor, information includes - relationship of the donor to the recipient (if any) - clinical information - information on organ recovery - histocompatibility
Data collection for transplant registries
True or false: A patient health record is a secondary data source.
False
____ are collections of secondary data related to patients with a specific diagnosis, condition, or procedure ex: - Alzheimer's Prevention Registry, Colon Cancer Family Registry, National and State Cancer Registries, Rare Disease Registry
Disease Registries
Follow-up - annually, the cancer registry attempts to obtain information about each patient in the registry, including whether they are still alive, status of the cancer, and treatment received during the period - various methods are utilized to obtain this information (facility-based registry: the healthcare organization's patient health records may be checked for return hospitalizations or visits for treatment or the patient's physician may be contacted to determine whether the patient is still living and to obtain info about the cancer) when patient status cannot be determined using these methods, an attempt may be made to contact the patient directly using information in the registry, such as the patient's address and telephone number or using information from the registry to contact relatives in order to obtain information on the patient - other methods include reading the newspaper obituaries for deaths and using the Internet to locate patients through sites such as the Social Security Death Index - the information obtained through follow-up is information and allows the registry to develop statistics on survival rates for specific cancers and different treatment methods Populati
Follow-up for Cancer Registries
HIM professionals are often involved in various roles using secondary data - roles include gathering information from secondary data sources, analyzing the data from the data source, or assisting in maintaining the privacy and security of data sources healthcare job titles for individuals working with registries may vary from entity to entity, but includes - cancer registry specialist - certified tumor registrar - HIM technician birth registry - registry coordinator - manager registry services - trauma registry coordinator - data analyst many HIM professionals may work with healthcare databases - databases manager, database specialist, database administrator, data abstractor, HIM administrative assistant as the healthcare environment continues to rely on accurate and reliable information, HIM professionals may find themselves working in the world of secondary data in new and emerging ways
HIM roles
a major initiative for AHRQ has been the _____ - uses data collected at the state level from either claims data or discharge-abstracted data, including UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers - data reported varies by state - data may be reported by the healthcare organizations to a state agency or to the state hospital association, depending on state regulations - data are then reported from the state to AHRQ, where they become part of the ____ databases ___ consists of a set of databases, including - Nationwide inpatient sample (NIS) (inpatient database from a sample of hospitals) - State inpatient database (SID) (hospital discharge database) - Nationwide emergency department sample (NEDS) (database on emergency departments) - state emergency department databases (SEDD) (database on hospital emergency departments) - Kids inpatient database (KID) (database of inpatient discharge data on children)
Healthcare Core and Utilization Project (HCUP)
____ is research concerning healthcare delivery systems, including organization and delivery and care effectiveness and efficiency within the federal government, the organization most involved in ____ is the Agency for Healthcare Research and Quality (AHRQ) - looks at issues related to the efficiency and effectiveness of the healthcare delivery system, disease protocols, and guidelines for improved disease outcomes databases are unique because they include data on inpatients whose case is paid for by all types of payers, including Medicare, Medicaid, private insurance, self-paying, and uninsured patients data elements include demographic information, diagnoses and procedures information, admissions and discharge status, payment sources, the hospital or freestanding ambulatory surgery center researchers may use these databases to look at issues such as those related to the costs of treating particular diseases, the extent to which treatments are used, and differences in outcomes and cost for alternative treatments
Healthcare services research
the ____ is an overall severity measurement calculated from the AID scores for patients with multiple injuries
Injury Severity Score (ISS)
the NLM produces two databases of special interest to the HIM Manager
MEDLINE UMLS
____ is the best-known database from the NLM - includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine HIM managers use ____ to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities
Medical Literature, Analysis, and Retrieval System Online (MEDLINE)
the ____ is made up of acute-care hospital and skilled nursing facility (SNF) claims data for all Medicare claims consists of the following types of data - demographic data on the patient - data on the provider - information on Medicare coverage for the claim - Total charges - covered charges - charges broken down by specific type of service, such as operating room, physical therapy, pharmacy charges - ICD diagnosis and procedure codes - MS-DRGs The ____ is frequently used for research on topics such as charges for particular types of care and MS-DRGs - the limitation of the ___ data for research purposes is that the file contains only Medicare patients
Medicare Provider Analysis and Review (MEDPAR) File
the ____ was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medical staff privileges) taken by healthcare organizations such as hospitals against physicians, dentists, suppliers, and other healthcare providers the ___ was developed to alleviate the lack of information about malpractice decisions, denial of medical staff privileges, and loss of medical license - because these data were not widely available, physicians whose license to practice was revoked in one state or healthcare organization could easily move to another state or healthcare organization and begin practicing again with the current state or healthcare organization being unaware of previous actions against the physician information in the ___ is provided through a required reporting mechanism - entities making malpractice payments, including insurance companies, boards of medical examiners, and entities such as hospitals and professional societies, must report to the ___ - info reported includes info about the practitioner, the reporting entity, and the judgment or s
National Practitioner Data Bank (NPDB)
the ____ collects data on the residential care community and adult day services sectors, and administrative data on home health, nursing home, and hospice sectors
National Study of Long-Term Care Providers
the _____ collects information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and men's and women's health information is collected from personal interviews, from men and women between 15-44 years of age
National Survey of Family Growth
the ____ has a certification program for state population-based registries Certification is based on the quality of data collected and reported by the state registry ____ has developed standards for data quality and format and works with other cancer organizations to align their various standards sets
North American Association of Central Cancer Registries (NAACCR)
____ is the area of healthcare dealing with the health of populations in geographic areas such as states or counties publicly reported healthcare data vary from quality and patient safety measurement data to patient satisfaction results - aggregate data range from a local to a national perspective, such as state-specific public health conditions to national morbidity and mortality statistics. - consumers are becoming more actively involved in their healthcare (publicly reported data may be presented for consumer used through various star ratings on different quality measures via organizations such as The Leapfrog Group, HealthGrades, or Hospital Compare) one duty of public health agencies is surveillance of the health status of the population within their jurisdiction - databases developed by public health departments provide information on the incidence and prevalence of diseases, possible high-risk populations, survival statistics, and trends over time - data for the databases may be collected using a variety of methods, including interviews, physical exams of individuals, review of health records (HIM manager may have input in these databases through data provided from health record
Public Health National, State, and County Public Health Databases
___ are different than indexes because they contain more extensive data index reports are usually produced using data from the healthcare organization's existing databases ____ often require more extensive entry of data from the health record the sole purpose of some ___ is to collect data from health records and make them available for users - other ___ take further steps to enter additional information in the ___ database, such as routine follow-up of patients at a specified interval (may include rate and duration of survival and quality of life over time)
Registries
Formal reporting of cancer registry data is done annually - the annual report includes aggregate data on the number of cases in the past year by site and cancer type (may also include info on patient's age, gender, ethnic group) other reports are provided as needed - data from the cancer registry are frequently used in the quality assessment process for a healthcare organization as well as in research - data on survival rates by site of cancer and methods of treatment, for instance, would be helpful in researching the most effective treatment for a type of cancer
Reporting for Cancer Registries
Secondary data are used for multiple reasons including: a. Assisting researchers in determining effectiveness of treatments b. Assisting nurses in providing patient care c. Billing for services provided to the patient d. Coding diagnoses and procedures treated
a. Assisting researchers in determining effectiveness of treatments
Identify an instance of patient-identifiable data. a. The patient was born on March 10 and lives at 123 Main Street b. The patient has both cancer and end-stage renal disease and has dialysis three times a week. c. There were 50 Medicare patients treated today. d. Of all our patients 50 percent have commercial insurance.
a. The patient was born on March 10 and lives at 123 Main Street
Which of the following acts mandated establishment of the National Practitioner Data Bank? a. Health Care Quality Improvement Act of 1986 b. Health Insurance Portability and Accountability Act of 1996 c. Safe Medical Devices Act of 1990 d. Food and Drug Administration Modernization Act of 1997
a. Health Care Quality Improvement Act of 1986
I started work today on a clinical trial and need to familiarize myself with the rules and procedures to be followed. This information is called the: a. Protocol b. MEDPAR c. UMLS d. HCUP
a. Protocol
the ____ reflects the nature of the injury and its threat to life by each body system - may be assigned manually by the registrar or generated as part of the database from data entered by the registrar
abbreviated injury scale (AIS)
when a case is first entered into the cancer registry, it is assigned an ____, a number unique to the patient - number consists of the first digits of the year the patient was first seen at the healthcare organization, and the remaining digits are assigned sequentially throughout the year - ex: first case in a year is assigned 21-0001 (21 indicates the patient was seen in year 2021) listing patients in ____ order is a way to ensure all the cases have been entered into the registry
accession number
an ____ is a list of cases in a cancer registry in the order in which they were entered an ___ of all cases can be kept manually or provided as a report by the database software
accession registry
____ include data on groups of people or patients without identifying any patient individually - secondary data are most often considered ____ ex: statistics on the ALOS for patients discharged within a particular MS-DRG
aggregate data
After several visits to the hospital, a 75-year-old female has just been diagnosed with cancer. What is the first thing you would do to get this patient entered in the cancer registry? a. Assign a patient number b. Assign an accession number c. Assign a financial record number d. Assign a health number
b. Assign an accession number
____ collect information on newborns with birth defects often population based, these registries serve a variety of purposes - provide information on the incidence of birth defects to study causes and preventions - monitor trends in birth defects - target interventions for preventable birth defects
birth defects registries
Why is the MEDPAR File limited in terms of being used for research purposes? a. It only provides demographic data about patients. b. It only contains Medicare patients. c. It uses ICD-10-CM diagnoses and procedure codes. d. It breaks charges down by specific type of service.
b. It only contains Medicare patients.
An advantage of HCUP is that it: a. Contains only Medicare data b. Helps determine pay for performance c. Contains data on all payer types d. Contains bibliographic listings from medical journals
c. Contains data on all payer types
Which of the following indexes would be used if a physician wanted to conduct a study on patients who have had a C-section? a. Physician index b. Master patient index c. Operation index d. Disease index
c. Operation index
a physician will identify patients needing transplants - information about the patient is provided to the registry when an organ becomes available, the patient's information is matched with potential donors for donor registries, donors are solicited through community information efforts similar to those carried out by blood banks to encourage blood donations
case definition and case finding for transplant registries
What type of registry maintains a database on patients injured by external forces in events out of their control? a. Implant registry b. Birth defects registry c. Trauma registry d. Transplant registry
c. Trauma registry
each registry must define the cases that are to be included; this process is called ____ ex: in a trauma registry, the ___ might be all patients admitted with a diagnosis that includes the ICD-10-CM trauma diagnosis codes
case definition
Birth defects registries use a variety of criteria to determine which cases to include in the registry. Some registries limit cases to those with defects found within the first year of life. Others include those children with a major defect that occurred in the first year of life and was discovered within the first five years of life - still, other registries include only children who were live born or stillborn babies with obvious birth defects cases may be detected in a variety of ways, including review of disease indexes, labor and delivery logs, pathology and autopsy reports, ultrasound reports, and cytogenic reports - in addition to information from hospitals and physicians, cases may be identified from rehab centers and children's hospitals and from vital records such as birth, death, and fetal death certificates
case definition and case finding for Birth Defects Registries
there are two types of diabetes mellitus: type 1 and type 2 diabetes. Registries sometimes limit their cases by type of diabetes - in some cases, there may be further definition by age, such as only including children with diabetes case finding includes the review of health records of patients with diabetes other case finding methods include review of: - diagnostic codes - billing data - medication lists - physician identification - health plans although facility-based registries for cancer and trauma are usually hospital based, facility-based diabetes registries are often found in physician offices or clinics - the office or clinic is the main location for diabetes care, thus data about the patient to be entered into the registry are available at these sites rather than at the hospital health plans are interested in optimal care for their enrollees because diabetics can have serious complications when not managed correctly - plans can provide information to the office or clinic on enrollees who are diabetics
case definition and case finding for diabetes registries
all children in the population area served by the registry should be included in the registry - some registries limit their inclusion of patients only to those seen at public clinics although children are usually targeted in immunization registries, some include information on adults for influenza and pneumonia vaccines children are often entered in the registry at birth - registry personnel may review birth and death certificates and adoption records to determine which children to include and which children toe exclude because they died after birth - in some cases, children are entered electronically through a connection with an electronic birth record system
case definition and case finding for immunization registries
implant registries sometimes include all types of implants, but often are restricted to a specific type of implant - ex: cochlear, silicone, temporomandibular joint
case definition and case finding for implant registries
a ____ is a research project in which new treatments and tests are investigated to determine whether they are safe and effective the ___ proceeds according to a protocol, which is the list of rules and procedures to be followed ___ databases have been developed to allow physicians and patients to find ___ - a patient with cancer or AIDS may be interested in participating in a __, but not known how to locate one related to their disease - ___ databases provide the data that enable patients and practitioners to determine what ____ are available and applicable to the patient the Food and Drug Administration Modernization Act of 1997 mandated that a _____ database be developed - the National Library of Medicine (NLM) has developed the database, available on the Internet by patients and practitioners (the NLM is a biomedical library that maintains and makes available a vast amount of print collections and produces electronic information resources on a wide range of topics)
clinical trial
Identify when an internal user might utilize secondary data. a. State infectious disease reporting b. Birth certificates c. Death certificates d. Benchmarking with other healthcare organizations
d. Benchmarking with other healthcare organizations
Patient data such as name, age, and address are known as: a. Primary data b. Secondary data c. Aggregate data d. Identification data
d. Identification data
____ of secondary data are individuals located within the healthcare organization ex: ____ include medical staff and administrative and management staff - secondary data enable these users to identify patterns and trends that are helpful to inpatient care, long-range planning, budgeting, and benchmarking with other healthcare organizations
internal users
A variety of information is abstracted for the birth defects registry, including - demographic information - codes for diagnoses - birth weight - status at birth, including live born, stillborn, aborted - cytogenetics results - whether the infant was a single birth or one in a multiple birth - mother's use of alcohol, tobacco, or illicit drugs - father's use of drugs and alcohol - family history of birth defects
data collection for birth defects registries
Joint Commission, CMS, and some health plans require healthcare organizations to collect data on core performance measures core performance measures - set of national standardized processes and best practices used to render and improve patient care - measures are secondary data because they are taken from the patients' health records whether a healthcare organization reports such measures will be a used as a basis for pay-for-performance systems - the goal is to link performance measures to provider payment (for example, helping the healthcare system move away from paying providers based on quantity to a system based on the quality of care rendered) (therefore, it is extremely important that the data accurately reflect the quality of care provided by the healthcare organization)
data for performance measurement
______ are developed for a variety of purposes - ex: the federal government developed ____ to carry our surveillance, improvement, and prevention duties - HIM managers may provide information for these ___ through data abstraction to state and local entities (may also use this data to perform research or work with other researchers on issues related to reimbursement and health status)
databases
the _____ is a listing in diagnosis code number order of patients discharged from the healthcare organization during a specific time period - each patient's diagnoses are converted from a verbal description to a numerical code, usually ICD-10-CM - the patient's diagnosis codes are entered into the healthcare organization's health information system as part of the discharge processing of the patient's health record the index always includes the patient's health record number as well as the diagnosis codes so health records can be retrieved by diagnosis because each patient is listed with the health record number, which may be linked to the patient's name and other information, the _____ is considered patient-identifiable data - may also include info such as date of discharge and attending physician's name
disease index
Trauma registrars may be - RHITs - RHIAs - RNs - LPNs - EMTs - other health professionals training for trauma registrars is through workshops and on-the-job training the American Trauma Society (ATS) provides core and advanced workshops for trauma registrars and a certification exam for trauma registrars who meet its education and experience requirements through its Registrar Certification Board - Certified trauma registrars have earned the certified specialist in trauma registry (CSTR) credential
education and certification of trauma registrars
____ initiatives were developed to move toward a longitudinal patient record with complete information about the patient available at the point of care - the data are patient-specific rate than aggregate and are used primarily for patient care some researchers have looked at the amount of data available through HIEs as a possible source of data to aggregate for research aggregate data can be deidentified to add another layer of protection for the patient's identity
health information exchange (HIE)
as a rich source of data about an individual patient, the ____ primary purpose is inpatient care and reimbursement for individual encounters
health record's
there is a scheduled list of immunizations children are supposed to receive during the first six years of life - these immunizations are so important that the federal government has set several objectives related to immunizations in Healthy People 2020, a set of health goals for the nation (includes increasing the proportion of children and adolescents that are fully immunized and increasing the proportion of children in population-based immunization registries) ___ usually have the purpose of increasing the number of infants and children who receive the required immunizations at the proper intervals - to accomplish this goal, registries collect information within a specific geographic area on children and their immunization status they help by maintaining a central source of information for a child's immunization history, even when the child has received immunizations from a variety of providers - this central location for immunization data relieves parents of the responsibility of maintaining immunization records for their children and helps ensure there is immunization data on children
immunization registries
an implant is a material or substance inserted into the body, such as breast implants, heart valves, and pacemakers ____ have been developed for the purpose of tracking the performance of implants including complications, deaths, and defects resulting from implants, as well as implant longevity in the recent past, there has been questions regarding safety of implants - such as the safety of silicone breast implants and temporomandibular joint implants and when such cases arise, it has often been difficult to ensure all patients have been notified of safety concerns - a number of federal laws have been enacted to regulate medical devices, including implants - first covered under Section 15 of Food, drug, and cosmetic act - the Safe Medical Devices Act of 1990 was passed and was amended through the Medical Device Amendments of 1992 (acts required a sample of healthcare organizations to report deaths and severe complications thought to be due to the manufacturer and the FDA through its MedWatch reporting system) - the MedWatch reporting system alerts health professionals and the public of safety alerts and medical device recalls ____ may help ensure compliance with legal reporting requir
implant registries
entities such as private accrediting organizations are required to report adverse actions to the data bank - in addition, adverse licensure and other actions against the healthcare organization, not just physicians and dentists, must be reported - adverse actions may include reporting incidents of licensure suspensions or revocations an ____ is an occurrence in a healthcare organization that is inconsistent with acceptable standards of care - may also include issues related to professional competence, an malpractice payments - monetary penalties may be assessed for failure to report the law requires healthcare organizations to query the NPDB as part of the credentialing process when a physician initially applies for medical staff privileges and every two years thereafter
incident
the most longstanding secondary data sources are those developed within healthcare organizations to meet their individual needs facility-specific ____ enable health records to be located by diagnosis, procedure, or physician - prior to extensive computerization in healthcare, these ____ were kept on cards (today, most ____ are maintained as computerized reports based on data from databases routinely developed in a healthcare organization)
indexes
data is extracted from patient records and entered into databases because
it is difficult to see trends in a population of patients by looking at individual health records - data may be used in a facility-specific or population-based registry fo research and improvement of patient care - data may be reported to the state and become part of state- and federal-level databases used to set health policy and improve healthcare
the ____ is arranged in numerical order by the patient's procedure code(s) using ICD-10-PCS or CPT codes information listed in the ____ is similar to that of the disease index, except that the surgeon may be listed in addition to, or instead of, the attending physician
operation index
registries may be developed for any type of disease or condition other commonly kept types of registries are cystic fibrosis, cardiac, and registries for chronic disease management and gastroenterology a registry can be developed for administrative purposes - The National Provider Identifier (NPI) Registry enables users to search for a provider's national plan and provider enumeration system information, including the national provider identification number (a 10-digit unique identification number assigned to healthcare providers in the US)
other registries
with ____, the patient is identified within the data either by name, address, date of birth, or social security number or other government issued identification - the health record consists entirely of patient identifiable data (every fact in the health record relates to a particular patient identified by name) - secondary data may also be ___ (data may be entered into a database along with information such as the patient's name maintained in an identifiable form, such as a registry) data are ____ if the identity of the patient is linked via address, age, or another identifier - ex: if an individual can be identified using a combination of elements such as date of birth, zip code, gender, marital status, and phone number, this would be ____
patient-identifiable data
the ____ is a listing of cases organized by physician name or physician identification number - also includes the patient's health record number and may include other information, such as date of discharge the ___ enables users to retrieve information about a particular physician, including the number of cases seen during a specific time period
physician index
____ include information from more than one healthcare organization in a specific geographical area such as a state or region regarding cancer in ____, the emphasis is on identifying trends and changed in the incidence (new cases) of cancer within the area covered by the registry
population-based registries
The health record is considered a(n) __________ because it contains information about a patient that has been documented by the professionals who provided care or services to that patient a ____ is an original data source where the data are documented or collected by the provider of care
primary data source
Reporting varies among trauma registries - an annual report is often developed to show the activity of the trauma registry - other reports may be generated as part of the performance improvement process, such as self-extubation (patients removing their own tubes) and delays in abdominal surgery or patient complications (some hospitals report to the National Trauma Data Bank) Trauma registries may or may not follow up on the patients entered in the registry - when a follow-up is done, the emphasis is frequently on the patient's quality of life after a period of time unlike cancer, where the physician follow-up is crucial to detect recurrence, many traumatic injuries do not require continued patient care over time - thus, follow-up is often not given the emphasis it receives in cancer registries
reporting and follow-up for Trauma Registries
a cariety of reports can be developed from the diabetes registry - for facility-based registries, one report might keep up with laboratory monitoring of the patient's diabetes to allow intensive intervention with patients whose diabetes is not well controlled - another report might concern patients who have not been tested within a year or have not had a primary care provider visit within a year population-based diabetes registries might provide reporting on the incidence of diabetes for the geographic area covered by the registry - registry data may also be used to investigate risk factors for diabetes follow-up is aimed primarily at ensuring the patient with diabetes is seen by the physician at appropriate intervals to prevent complications
reporting and follow-up for diabetes registries
because the purpose of the immunization registry is to increase the number of children who receive immunizations in a timely manner, reporting should emphasize immunization rates - immunization registries can also provide automatic reporting of children's immunization to schools to check the immunization status of their students follow-ups are done to remind parents when it is time for immunizations as well as to identify parents who fail to bring the child in for the immunization after a reminder - reminders may include letters, emails, automatic reminder generated from the EHR, or telephone call or autodialing systems registries must decide how frequently to follow up with parents who do not bring their children in for immunization - maintaining up-to-date addresses and telephone numbers is important for providing follow-up - in some states, registries may allow parents to opt out of the registry if they prefer to not be reminded
reporting and follow-up for immunization registries
reporting includes information on donors and recipients as well as survival rates, length of time on the waiting list for an organ, and death rates follow-up information is collected for recipients as well as living donors - for living donors, the information collected might include complications of the procedure and length of stay in the hospital follow-up on recipients includes information on status at the time of follow-up (living, expired, list to follow-up), functional status, graft status, treatment such as immunosuppressive drugs - follow-up is carried out at intervals throughout the first year after the transplant and then annually after that
reporting and follow-up for transplant registries
HIM professional can play a variety of roles in managing secondary data and databases - database setup - determining the content of the database - ensuring compliance with laws, regulations, accreditation standards affecting content and use of database (all data elements included in the database or registry must be defined in a data dictionary) HIM professional serves as a data steward to oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry - "Data stewardship is a responsibility guided by principles and practices to ensure the knowledgeable and appropriate use of data derived from individuals' personal health information"
role of HIM professional
___ sources consist of - facility-specific indexes - registries, either facility or population-based - other healthcare databases
secondary data
data derived from the primary health record, such as an index or a database, are considered _____ - these data are known as secondary data
secondary data sources
the CDC provides funding for some population-based immunization registries on recognition of the growing importance of the Immunization Information System (IIS) to the broader health information technology landscape, the 2001 IIS Minimum Functional Standards have been revised - the new standards are an attempt to lay the framework for the development of IIS through 2018 - the new program goals and standards include objectives from Healthy People 2020
standards and approval processes for immunization registries
states frequently have health-related administrative databases ex: - many states collect UB-04 institutional data on patients discharged from hospitals located within their area
state administrative data banks
state and local public health departments develop databases, as needed, to perform their duties on health surveillance, disease prevention, and research - ex: - infectious or notifiable disease databases each state has a list of diseases that must be reported to the state - such as measles and syphilis - so that containment and prevention measures can be taken to avoid large outbreaks of these diseases state and local reporting systems connect with the CDC through NEDSS to evaluate trends in disease outbreaks - may also be statewide databases or registries that collect extensive information on particular diseases and conditions such as birth defects, immunizations, and cancer
state and local health databases
____ may have varied purposes some organ ___ maintain databases of patients who need organs - when an organ becomes available, allocation of the organ to the patient is based on prioritization method in other cases, the purpose of the registry is to provide a database of potential donors for transplants using live donors, such as bone marrow transplants post-transplant information is kept on organ recipients and donors because transplant registries are used to try to match donor organs with recipients, they are often national or even international in scope examples of national registries include - UNet of the United Network for Organ Sharing (UNOS) - registry of the National Marrow Donor Program (NMDP) data collected in the ___ may be used for research, policy analysis, and quality control
transplant registries
____ maintain databases on patients with severe traumatic injuries a traumatic injury is a wound or other injury caused by an external physical force such as a motor vehicle crash, a gunshot wound, a stabbing, or a fall information in the ____ may be used for performance improvement and research in the area of trauma care ___ may be facility-based or may include data for a region or state
trauma registries
____ include data on births, deaths, fetal deaths, marriages, and divorces responsibility for collection of ___ rests with the states - states share information with NCHS - actual collection of data is at the local level one ___ database at the national level includes the Linked Birth and Infant Data Set - data from birth certificates are compared to death certificates for infants less than one year of age - database provides data to conduct analyses for patterns of infant death other national databases using ___ include National Mortality Followback Survey, National Maternal and Infant Health Survey, National Survey of Family Growth, National Death Index at the state level, ____ data is used for birth defect registries
vital statistics