HEALTH INFORMATION MANAGEMENT CHAP.5

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HEALTHCARE DATA SETS AND STANDARDS By Kathy Giannangelo

The name of the government agency that has led the development of basic data sets for health records and computer databases is the

National Committee on Vital and Health Statistics

The primary purpose of a minimum data set in healthcare is to

recommend common data elements to be collected in health records

Data that are collected on large populations of individuals and stored in databases are referred to as

aggregate data

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the

Uniform Hospital Discharge Data Set

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for

performance improvement programs

National Health Information Network is

A network of networks

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of

vocabulary standards

The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the

Health Insurance Portability and Accountability Act of 1996

The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the

Social Security number

Most healthcare informatics standards have been implemented by

state regulation

A critical early step in designing an EHR is to develop a(n) ___ in which the characteristics of each data element are defined.

data dictionary

According to the UHDDS definition, ethnicity should be recorded on a patient record as

Hispanic, non-Hispanic, unknown

Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?

DEEDS

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on

reason for encounter

In long term care, the resident's care plan is based on data collected in the

MDS Version 2.0

Reimbursement for home health services in dependent of data collected from

OASIS

A consumer interested in comparing the performance of health plans should review data from

HEDIS

I need a standard that allows data to be transferred across the Internet. Which of the following is my choice?

XML

Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for

CORE DATA ELEMENTS

A statewide cancer surveillance system is an example of which of the NHII dimensions?

COMMUNITY

In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?

X12N

A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is

DICOM

A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is

CONTINUITY OF CARE RECORD

Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?

LOINC

As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for

harmonization of standards from multiple sources

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