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Sayles Chapter 12 (Healthcare Information)
Terms in this set (41)
personal health record
A _____ is a record created and managed by an individual in a private, secure, and confidential environment.
is the science of examining raw data with the purpose of drawing conclusions about that information. The role of this depends on the type of data being captured, reviewed, and used for the purpose of turning it into healthcare information.
- Descriptive analytics - "what happened?"
- Diagnostic analytics - "why did it happen?"
- Predictive analytics - "what will happen?"
- Prescriptive analytics - "how can we make it happen"
What are the different types of analytics?
Healthcare data analytics
is the practice of using data to make business decisions in healthcare.
Clinical data analytics
is the process by which health information is captured, reviewed, and used to measure quality of care provided.
step 1 : data capture, which helps ensure the data needed is available and that the data is correct.
step 2 : data provisioning, which ensures that the data is in a format that can be manipulated for data analysis.
step 3 : data analysis, where data is interpreted and transformed from raw data into meaningful analytics.
What are certain steps that must occur in order to prepare healthcare data for data analysis?
FYI (for your information)
FYI: Tables are used to organize quantitative data or data expressed as numbers. Charts (such as pie and bar charts) and graphs (such as line graphs) are appropriate when presenting relationships. Each tool has specific features to keep in mind when depicting the data.
is a data analytics tool which is used as a management report of process measures. HIM professionals use this to monitor a number of indicators to improve performance and meet the quality goals such as reducing infection rate. They provide early warnings signals and alerts the manager of areas in need of attention so organizational performance is improved.
(They are also used to manage revenue cycle management performance. For example, the Healthcare Financial Management Association or HFMA has a web-based application called MAP App for use by healthcare providers to check revenue cycle performance and evaluate against provider peer groups. HFMA's key performance indicators can be used to track, monitor, and improve revenue cycle performance.)
This reports outcomes measures.
is a quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria. For example, this could monitor death rates or infections.
is the process of recording data in a health record system or database.
is an organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
relational database, which stores data in predefined tables consisting of rows and columns.
What is one of the most common healthcare databases?
the information is entered into the health record at the time and location of service. Nurses entering data using a tablet as they conduct patient assessments while at the bedside is an example of this.
A device used by humans to access and enter data into a computer system.
human-readable data are ______, whereas machine readable data are ______.
represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values
FYI (for your information)
FYI: When considering methods for EHR data capture, follow these best practices:
• Consider what data needs to be captured and customize available tools to collect it.
• Evaluate the data and determine its placement in the record to determine what rules or procedures are needed to upload the information most efficiently and without errors.
• Collect the data in a standardized format using templates or discrete fields to make retrieval for reporting easier.
• Routinely audit a sample of records that are collected using the data capture methods described.
• Acquire primary and secondary data from existing internal or external data sources
FYI (for your information)
FYI: Data capture may also occur with word processing software. The word processing copy and paste functionality in EHR systems must be carefully monitored, and limited or prohibited to prevent data quality issues. Measures for preventing data quality problems include the following.
• Clearly label the information as copied from another source
• Limit the ability for data to be copied and pasted from other systems
• Limit the ability of one author to copy from another author's documentation
• Allow a provider to mark specific results as reviewed
• Allow only key, predefined elements of reports and results to be copied or imported
• Monitor a clinician's use of copy and paste
natural language processing
a technology that converts human language (structured or unstructured) into data that can be translated and then manipulated by computer systems.
FYI (for your information)
FYI: Back-end speech recognition (BESR) is a specific use of speech recognition technology (SRT) in an environment where the recognition process occurs after the completion of dictation by sending voice files through a server. In BESR, an employee edits or corrects the dictation. Front-end speech recognition (FESR) is a process where the provider speaks into a microphone or headset attached to a PC and upon speaking, the words are displayed as they are recognized. In FESR, the physician corrects misrecognitions at the time of dictation. Use of FESR integrated with an EHR provides the best outcome, as the provider is able to respond to prompts from the EHR resulting in more complete, accurate, and timely documentation
is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors. It is a key piece of analytics and of the knowledge discovery process. (For example, it can be used to detect early signals of potential adverse drug events. Other applications are used for the evaluation of treatment effectiveness, management of healthcare, customer relationship management, and detection of fraud and abuse.)
Clinical data repository
is a central database that focuses on clinical information.
Clinical data warehouse (CDW)
allows access to data from multiple databases and combines the results into a single query and reporting interface.
Decision Support System (DSS)
is a computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems. It is primarily used by management for operational as well as strategic decisions.
clinical decision support system (CDSS)
is a "special subcategory of clinical information systems designated to help healthcare providers make knowledge-based clinical decisions"
Executive information system (EIS)
is a system that facilitates and supports senior managerial decisions.
is the field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies
is a system that allows consumers to log in to a secure online website to gain access to personal health information and navigate around it once inside the system.
(Sharing patient information providers expands the depth, breadth, and continuity of information resulting in the potential of improved healthcare outcomes.)
What is one important piece of patient-centered healthcare tools?
for your information (FYI)
• Standalone: Patients fill in information they want to share with their healthcare provider. The information is stored on patients' computers or through an online system. Some standalone PHRs accept data from external sources, such as healthcare providers and laboratories. Patients choose with whom they share the information.
• Tethered or connected: A type of PHR that is linked to a specific healthcare organization's EHR. A tethered PHR allows patients to access their own records through a secure portal.
What are the two types of PHR
Health Information Exchange (HIE)
an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information
Directed Exchange (type of HIE)
is the "ability to send and receive secure information electronically between care providers to support coordinated care. Examples of patient information include ancillary test orders and results, patient care summaries, or consultation reports. The encrypted patient information is electronically sent securely between parties with an established relationship. For example, this type of exchange is used to report public health data.
Query-based exchange (type of HIE)
is the "ability for providers to find and/or request information on a patient from other providers, often used for unplanned care.... This type of exchange is used to search and discover accessible clinical sources on a patient." For example, it can assist a provider in obtaining a health record on a patient who is visiting from another state, resulting in more informed decisions about the care of the patient.
Consumer-mediated exchange (type of HIE)
is the "ability for patients to aggregate and control the use of their health information among providers." For this form the patient is the driver, not the provider. For example, a patient portal may allow personal health information to be uploaded for provider access.
• Reduction of duplicative treatments
• Elimination of redundant or unnecessary testing
• Less medication and medical errors, which can be costly and have a negative impact on the patient
• Increased patient safety
• Achievement of a basic level of interoperability
• More informed decision making for more effective care and treatment
• Improved public health reporting and monitoring
• Improved transitions of care
• Improved population health
• Improved efficiency in the healthcare system
• Reduction in paperwork, allowing more time for discussions about health concerns and treatments
What are some benefits of Health Information Exchange (HIE)?
The data must be accurately collected, entered, and queried
What are three events that must occur in order to maintain patient identity data integrity?
• Not requiring proof of identification at the time data are collected
• Not making accurate registration a priority in the emergency department
• Data quality issues with patient identification data stored and managed in siloed legacy systems
• Not correcting data errors in a timely and comprehensive manner
What are some of the challenges when trying to maintain patient identity data integrity?
are "documented agreements on representations, formats, and definitions of common data"
(Vocabulary, code set, and terminology standards represent the meaning of the clinical data. For example, LOINC is a data standard for representing lab tests.)
roles for HIM professionals in HIE
defining the data exchange model, developing guidelines for data stewardship and data governance, developing data integrity and quality standards, identifying strategies to ensure accurate patient identity, ensuring that privacy and security requirements are met, and performing provider and patient education about why HIE is important are all considered what?
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