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Health Information Technology Ch. 6 Data Management
Terms in this set (47)
Both clinical and administrative
Data stored in the EHR
Billing and quality improvement data
Picture archival and communications
Electronic Health Record
Data or Data Element
One fact or measurement
A single fact that represents the smallest unique subset of a larger database.
A listing of all the data elements within a specific system that defines each individual data element
National Center for Health Statistics
National Committee on Vital and Health Statistics
A recommended list of data elements that have defined and uniform definitions *specific criteria) that are relevant for a particular use
Uniform Ambulatory Care Data Set
Uniform Hospital Discharge Data Set - Collect uniform data elements from the health records of every hospital
Data Elements for Emergency Department Systems
Minimum Data Set - Long Term Care Setting
Outcomes and Assessment Information Set - Home Healthcare Setting
Essential Medical Data Set - Emergency Care Settings
Collection of data
Database Life Cycle
DBLC 6 Steps
1. Initial study
4. Testing and evaluation
5. Operation (use of database)
6. Database maintenance and evaluation
Report or list from a database that provides guidance to the data contained in the database.
Master Patient Index
Guide to locating specific demographic information such as name, etc.
Listing of specific codes, such as ICD (International Classification of Disease)
Operation or Procedure Index
Specific codes such as CPT - Current Procedure Terminology for procedures or operations performed within the facility
A listing of all physicians within an organization with all the diagnosis and procedure codes linked to the provider within the index.
Allows for connections between two coding systems.
The process of collecting the data from different data sources within an organization
A single database that makes if possible to access data that exists in multiple databases through one single query and reporting interface
The process of extracting from a database or data warehouse information stored in discrete structured format.
'Enterprise authority that insures control and accountability for enterprise data'
AHIMA 8 Principles to support information governance
Creates responsibility for data through principles and practices
The assurance that the data entered or maintained into a system are only accessed and amended by those with the authority to do so.
Allows sharing information to be exchanged via electronic formats
Capability of two or more info systems and software applications to communicate
SDO - Standards Development Organizations
In the USA they are managed by the American National Standards Institute - ANSI
Private or gov.'t agencies that are involved in the creation and implementation of healthcare standards.
Data interchange standards goals
To facilitate consistent, accurate and reproducible capture of clinical data
American National Standards Institute
Organization that oversees the creation of data standards from a variety of business sectors, including healthcare.
Health Level 7
ANSI accredited SDO, established for the creation of standards to support the exchange of clinical info in multiple formats DIGITAL IMAGING, and COMMUNICATION IN MEDICINE
IEEE - Institute of Electrical and Electronics Engineers
Organization that creates standards for HOSPITAL SYSTEMS
Information collected during day to day operations of a healthcare organization
Refers to the process of analyzing, assessing, etc., to provide outcomes to a problem.
"Any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient's medical condition or treatment" (HESS 2015)
AHIMA Data Quality Management Model - 10 points
Accessibility - Make sure data is available when needed
Comprehensiveness - Certifies that all required data that should be collected are documented.
Consistency - Ensuring the patient data is reliable.
Currency - The data is current and up to date.
Definition - All data elements are clearly defined.
Granularity - The Data must be at the appropriate level of detail.
Precision - Data should be precise.
Relevancy - Data is useful for the purpose for which it is collected.
Data Quality Management Domains
Clinical Documentation Improvement
Communication tool for CHI staff to communicate with providers to obtain clinical clarification.
Written documents that provide details and information regarding the rules established by a healthcare organization.
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