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Secondary Data Sources 2

Terms in this set (68)

Aggregate Data
Include data on groups of people or patients without identifying any particular patient individually. Example, statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis related group (DRG)
Primary data source
The health record is considered a primary data source because it contains information about a patient that has been documented by the professionals who provided care or services to that patient.
Secondary data sources
Data derived from the primary patient record, such as an index or a database, are considered.
Health record's primary purpose is
in patient care and reimbursement for individual encounters.
The health Information Management (HIM) professional can play a variety of roles
In managing secondary records and databases. They play a key role to help set up databases.
All data elements included in the database or registry must be defined in a
Data dictionary.
Data Dictionary
A descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use.
The HIM professional may serve as a
data steward to oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry.
Four major purposes for collecting secondary data
1.The first is for quality, performance, and patient safety. Example, Healthcare facilities, collect core measures information from the health record for the centers for Medicare and Medicaid Services (CMS) to evaluate the quality of care within the facility.
2. the second area of use is research. Data taken from health records and entered into disease oriented databases can help researchers determine the effectiveness of alternate treatment methods. They also can quickly demostrate survival rates at different stages of diseases.
3. The third major use is for population health . Example, states require information be reported to them on certain diseases so the extent of the disease can be determined and steps taken to prevent its spread.
4. The final use of secondary data is for administration. For instance, in credentialing physicians, facilities are required to access a national database for information on previous malpractice or other adverse decisions against a physician.
Internal Users
Individuals located within the healthcare facility. For example, medical staff and administrative and management staff. Secondary data enables these users to identify patterns and trends that are helpful in patient care, long range planning, budgetting , and benchmarking with other facilities.
External users
of patient data are individuals and institutions outside the facility. Examples are state data banks and federal agencies. States have laws mandating cases of health of patients with diseases such as tuberculosis and AIDS be reported to the state department.
The secondary data provided to external users are generally
aggregate data and not patient identifiable data.
Secondary data sources consist of
Facility specific indexes.
Registries
Either facility or population based; or other healthcare databases.
Indexes
1.Enable health records to be located by diagnosis, procedure, or physician. 2. An organized (usually, alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data.Before computerization in healthcare, these Indexes on cards. Today, most indexes are maintained as computerized reports.Index reports can usually be produced using data from the patient record.
Disease Index
Is a listing in diagnosis code number order of patients discharged from the facility during a particular time period. The Index always includes the patient's health record number as well as the diagnosis codes so records can be retrieved by diagnosis. Disease index is considered patient identifiable data. DI also may include information such as the attending physician's name and the date of discharge.
Operation Index
It is similar to the Disease Index except that it is arranged in numerical order by the patient's procedure codes using ICD or Current Procedural Terminology (CPT) codes. The other information entered is as same as DI except that the surgeon may be listed in addition to, or instead of , the attending physician.
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. The PI enables users to retrive information about a particular physician, including the number of cases seen during a specific time period.
Disease registries
1.Collection of secondary data related to patients with a specific diagnosis, condition, or procedure.2. A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery. Registries are different from indexes in that they contain more extensive data. Registries often require more extensive entry of data from the patient record.
Case definition
Each registry must define the cases that are to be included, this process is called case definition. Example, in a trauma registry , the case definition might be all patients admitted with a diagnosis falling into the ICD trauma diagnosis codes.
Case finding
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.
The sole purpose of some registries is
to collect data from health records and make them available for users.
Cancer registries
have a long history in healthcare. According to (NCRA) National Cancer Registrars Association the first hospital cancer registry was founded in 1926 at yale New Haven Hospital. These registries were developed as an organized method to collect these data. The data may be facility based for example, within a hospital or clinic or population based for example, from more than one facility within a state or region. These registries tracks the incidence (new cases ) of cancer.
Birth defects registries
Collects information on newborns with birth defects.
Trauma registries
Tracks patients with traumatic injuries from the initial trauma treatment to death.
Diabetes registries
Collects cases of patients with diabetes for the purpose of assistance in managing care as well as for research.
Implant registries
Tracks the performace of implants including complications, deaths, and defects resulting from implants, as well as implant longevity.
Transplant registries
Maintains databases of cases of patients who need organ transplants.
Immunization registries
Collects information within a particular geographic area on children and their immunization status and maintains a central source of information for a particular child's immunization history, even when the child has received immunizations from a variety of providers.
Facility based registry
A registry that includes only cases from a particular type of healthcare facility.for example, within a hospital or clinic. The data from facility based registries are used to provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment. The data collected also 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. In the facility based registry , the first step is case finding.
Population based registry
A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region. For example, from more than one facility within a state or region. In PBR s emphasis is on identifying trends and changes in the incidence (New cases) of cancer within the area covered by the registry. PBRs usually depend on hospitals, physician offices, radiation facilities, ambulatory surgery centers(ASCs) and pathology laboratories to identify and report cases to the central registry. The administrative of a PBRs have a responsibility to ensure that all cases of cancer have been identified and reported to the central registry.
National Library of Medicine (NLM)
produces two databases of special interest to the HIM manager MEDLINE and UMLS.
Medical Literature, Analysis, and Retrieval System Online (MEDLINE)
Is the best known database from the NLM. It includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine. HIM managers use MEDLINE to locate articles on HIM issues as well as articles on medical topics necessary to carry out quality improvement and medical research activities.
Unified Medical Language System (UMLS)
Provides a way to integrate biomedical concepts from a variety of sources to show their ralationships. This process allows links to be made between different information systems for purposes such as electronic health record systems. UMLS is of particular interest to the HIM manager because of medical vocabularies such as ICD- 10- CM, CPT, and the healthcare commong procedure coding systems (HCPCS)
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. This is patient specific rather than aggregate data and is used primarily for patient care.
Data for measurment
The Joint Commision, CMS< and some health plans require healthcare facilities to collect data oncore performance measures. These measures are secondary data because they are taken from patient medical records.
Clinical Trial
Is a research project in which new treatments and tests are investigated to determine whether they are safe and effective. The trail proceeds according to a protocol. Clinic trials databases provide data that enables patients and practitioners to determine what clinical trials are available and applicable to the patient. The Food and Drug Administration Modernization Act of 1997 mandated that a clinical trials database be developed. National Library of Medicine (NLM) has developed the database, available on the Internet for use by both 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.
Protocol
Which is the list of rules and procedures to be followed.
Vital Statistics
Include data on births, deaths, fetal deaths, marriages, and divorces. The states share information with the NCHS.The state serves as the official repository for the certificate and provides vital statistics information to the National Center for Health Satistics (NCHS).
National Health Care Survey
One of the major national public health surveys . To a large extent, it relies on data from patients health records. It consists of a number of parts National Hospital Care survey, National Survey of Ambulatory Surgery, National Nursing Home Survey, National Home and Hospice Care Survey.
Data in the National Hospital Care Survey
is a combination of data from the National Hospital Discharge Survey (NHDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS)
Data for the National Survey of Ambulatory Surgery
are collected on a representative sample of hospital based and freestanding ambulatory surgery centers. Data include patient demographic characteristics, source of payment, and information on anesthesia given, diagnoses, and surgical and nonsurgical procedures on patient visits. It is a mailed survey about the facility and abstracts of patient data.
National Nursing Home Survey
Provides data on each facility, current residents,and discharged residents. Information is gathered through an interview process.The staff member uses the resident's health record for reference during the interview.
National Home and Hospice Care Survey
Data are collected on the home health or hospice agency as well as on their current and discharged patients. Data include referral and length of service, diagnoses, number of visits, patient charges, health status, reason for discharge, and types of services provided. Facility data are provided through an interview with the administrator or designee. Patient information is obtained from the caregiver most familiar with the patient's care. The caregiver may use the patient's health record in answering the interview questions.
Because of bioterrorism scares,
the CDC developed the National Electronic Disease Surveillance system (NEDSS) that serves as a major part of the Public Health Information Network (PHIN)
National Immunization Survey
Which collects data on the immunization status of children between the ages of 19 months and 35 months living in the United States.
Each state has a list of diseases that must be reported to the
state such as AIDS, 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.
State and local public health departments
also develp databases, as needed, to perform their duties of health surveillance, disease prevention, and research.
Accession number
A number assigned to each case as it is entered in a cancer registry.
Accession registry
A list of cases in a cancer registry in the order in which they were entered.
Demographic Information
Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person.
Facility based registries
A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic.
Incident
An occurance in a medical facility that is incosnsistent with accepted standards of care.
Population based registry
A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region.
Trauma center Level I
Able to provide total care for every aspect of injury from prevention through rehabilitation.
Trauma center level II
Able to initiate definitive care for all injured patients.
Trauma center level III
Able to provide prompt assessment, resuscitation, surgery, intensive care, and stabilization of injured patients and emergency operations.
Trauma center level IV
Able to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher level trauma center; provides evaluation, stabilization, and diagnostic capablilities for injured patients.
Trauma center level V
Able to provide initial evaluation, stabilization, and diagnostic capabilities, and prepares patients for transfer to higher levels of care.
The Injury Severity Score (ISS)
Is an overall severity measurement calculated from the AIS scores for patients with multiple injuries.
Abbreviated Injure Scale (AIS)
Reflects the nature of the injury and its threat to life by body system.
Public health
is the area of healthcare, dealing with the health of populations in geographic areas such as states or counties.
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 licensure actions,(such as denial of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers as well as private accrediting organizations and peer review organizations.
North American Association of Central Cancer Registries (NAACCR)
has a certification program for state population based registries. Certification is based on the quality of data collected and reported by the state registry. NAACCR has developed strandards for data quality and format and works with other cancer organizations to align their various standards sets.
Centers for Disease Control and Prevention (CDC)
Has national standards regarding the completeness, timeliness, and quality of cancer registry data from state registries through the National program of Cancer Registries (NPCR)
American College of Sugeons (ACS) Commision on Cancer
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.
Transparency
Refers to the degree to which patients included in secondary data sets are aware of their inclusion.
Staging System
A method used in cancer registers to identify specific and separate different stages or aspects of the disease
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