Fundamental of Health Information, Chapter 7 Secondary Data Sources

Stage of the neoplasm

Specifies the amount of metastasis

National Electronic Disease Surveillance (NEDSS)

This system provides a national surveillance system by connecting the CDC with local and state public health partners. It allows CDC to monitor for trends from disease reporting at the local and state levels to look for possible bioterrorism incidents.

Glycated Hemoglobin-HbA1c

This test is used to determine the patient's blood glucose for a period of approximately 60 days prior to the time of the test.

Diabetes Mellitus

Type 1, Type 2 Registries sometimes limit their cases by type of diabetes.

Collaborative Stage Data Set

Uses computer algorithms to describe how far a cancer has spread.

Healthcare Cost and Utilization Project (HCUP)

Uses data collected at the state level from either claims data or discharge-abstracted data, including the UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers.

National Practitioner Data Bank (NPDB)

Was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments, adverse and licensure actions.

American College of Surgeons (ACS) Commission on Cancer

Approval process for cancer programs.

National Survey for Ambulatory Surgery

Are collected on representative sample of hospital-based and freestanding ambulatory surgery centers.' Data includes patient demographic characteristics, source of payment, and information on anesthesia given, diagnoses, and surgical and non surgical procedures on patient visit.

Disease Registries

Are collections of secondary data related to patients with a specific diagnosis, condition, or procedure.

Healthcare Databases

Are developed for

External Users

Are individuals and institutions outside the facility. Ex: State data banks, federal agencies.

Internal Users

Are individuals located within the healthcare facility. ex: medical staff, administrative and management staff.

Primary Data Source

Contain information about a patient that has been documented by the professionals who provided care or services to that patient.

Health Services Research

is research concerning healthcare delivery systems, including organization and delivery and care effectiveness and efficiency.

Cancer Registries Amendment Act

1992 Provided funding for a national program of cancer registries.

Types of secondary data sources

1. Facility - specific indexes 2. Registries 3. Either facility or population based 4. Other healthcare databases

Purposes for collecting secondary data

1. Quality, performance, and patient safety. 2. Research 3. Population health. 4. Administration

ADL

Activity of Daily Living

CSTR

Certified Specialist Trauma Registrar

CTR

Certified Tumor Registrar

Birth Defects Registries

Collect information on newborns with birth defects.

National Home and Hospice Care Survey

Data are collected on the home health or hospices agency as well as on their current and discharged patients. Data includes referrals and length of service, diagnoses, number of visits, patient charges, health status, reason for discharge, and types of services provided.

Secondary Data Source

Data derived from the primary patient record, such as an index or a database, are considered to be secondary data source.

Facility Specific Indexes

Enables health records to be located by diagnosis, procedure, or physician.

North American Association of Central Cancer Registries (NAACCR)

Has certification program for state population-base registries.

Centers for Disease Control and Prevention

Has national standards regarding the completeness, timeliness, and quality of cancer registry data from state registries through the National Program of Cancer Registries (NPCR).

National Cancer Registrars Association (NCRA)

Has worked with colleges to develop formal educational programs for cancer registrars.

Implant Registries

Have been developed for the purpose of tracking the performance of implants including complications, as well as implant longevity.

Medicare Provider Analysis and Review (MEDPAR)

Is made up of acute care hospital and skilled nursing facility (SNF) claims for all medicare claims.

Medical Literature, Analysis, and Retrieval System Online (MEDLINE)

Is the best know database from the NLM. It includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine.

Immunization Registries

Healthy People 2020 sets health goals for the nation, including immunization. Collection of information within a particular geographic area.

IIS

Immunization Information System

Aggregate Data

Include data on groups of people or patients without identifying any particular patient individually.

Diabetes Registries

Includes cases of patients with diabetes for the purpose of assistance in managing care as well as for research.

Vital Statistics

Includes data on births, deaths, fetal deaths, marriages, and divorces.

Identifiable Data

Is when a patient is identified within the data either by name or number. examples: date of birth, zip code, gender, marital status and phone number.

Cancer Registries

National Cancer Registrars Association (NCRA )-. The first hospital cancer registry was founded in 1926. An organized method to collect data on Cancer

Health Information Exchange (HIE)

Initiatives were developed in an effort to move toward a longitudinal patient record with complete information about the patient available at the point of care.

Data Dictionary

Is a descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database.

Protocol

Is a list of rules and procedures to be followed.

Disease Indexes

Is a listing in diagnosis code number order of patients discharged from the facility during a particular time period.

Physician Index

Is a listing of cases in order by physician name or physician identification number. It also includes the patient's health record number and may include other information such as date of discharge.

Case Filing

Is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry.

Case Definition

Is a process in which each registry that defines the cases that are to be included. For example, In a trauma registry the case definition might be all the patients admitted with a diagnosis falling into the ICD trauma diagnosis codes.

Clinical Trials

Is a research project in which new treatments and tests are investigated to determine whether they are safe and effective.

Traumatic Injury

Is a wound or other injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall.

Public Health

Is an area of the healthcare dealing with the health of populations in geographic areas such as sates and counties.

Injury Severity Score

Is an overall severity measurement calculated from the AIS scores for patients with multiple injuries.

Operation Index

Is arranged in numerical order by the patient's procedure code(s) using ICD or Current Procedural Terminology (CPT) codes.

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.

NPCR

National Program of Cancer Registries Developed as a result of the Cancer Registries Amendment Act of 1992 The CDC collects data from the NPCR state registries

NVAC

National Vaccine Advisory Committee

Other Registries

Other commonly kept types of registries are HIV/AIDS, cardiac registries, and registries for chronic disease management and gastroenterology.

National Center for Health Statistics (NCHS)

Provides statistical, accurate, relevant, and timely data that helps to guide actions and policies to improve the health of the American people.

Unified Medical Language System (UMLS)

Provides a way to integrate biomedical concepts from a variety of source to show their relationships.

American Trauma Society (ATS)

Provides core and advance workshops for trauma registrars and also provides a certification examination for trauma registrars who meet their education and experience requirements through it's Registrar Certification Board.

National Nursing Home Survey

Provides data on each facility, current residents, and discharged residents. data collected on the facility include information on ownership, size, certification status, admission, services, full-time equivalent employees, and basic charges. also provides demographics on the resident as well as length of stay, diagnoses, level or care received, activities of daily living (ADL), and charges.

National Board for Certification of Registrars (NBCR)

Provides examination for certification for candidate/applicant to become a certified registrar.

National Hospital Care Survey

Provides information on the utilization of healthcare provided in inpatient settings, emergency departments, outpatient departments, and ambulatory surgery centers are collected inn one place.

PHIN

Public Health Information Network. also apart of the National Electronic Disease Surveillance (NEDSS).

Abbreviated Injury Scale (AIS)

Reflects the nature of the injury and its threat to life by body system.

Trauma Registrars

can be Registered Health Information Technicians (RHITs). Registered Health Information Administrators (RHIAs). Registered Nurses (RNs). License Practical Nurses (LPNs). Emergency Medical Technicians (EMTs). or other health professionals.

National Library of Medicine (NLM)

has develop the database, available on the Internet for the use by both patients and practitioners.

American Joint Committee on Cancer (AJCC)

has worked through it's Collaborative Stage Task Force with other organizations with staging systems to develop a new standardized staging system.

Trauma Registries

maintain databases on patients with severe traumatic injuries.

Transplant Registries

some organ transplant registries maintain databases of patients who need organs. also provide a database of potential doors for transplants using live donors, such as bone marrow transplants. and keep Post-transplant information on organ recipients and donors.