Chapter 4 - part 1 Wednesday summer class

tefetaxo's version from 2017-07-22 17:26

Section 1

Question Answer
What is a data element?One single fact or measurement
What is Information?It represents the meaning of the combined single data facts that have been converted, analyzed, interpreted to give the data meaning.
What is aggregate data?Data extracted from individual patients health records and combined into "groups".
A person's age is an example of what?Data element
Test results, combined with physicians observations, and patient symptoms is an example of what? Information
Data about all patients who suffered an acute myocrdial infarction during a specific time period could be collected in a database is an example of what? Aggregate data
What is a data set?A list of recommended data elements with uniform definitions that are relevant for a particular use. (Spell out what is going to be collected and what are the definitions for those elements that are going to be collected).
Creating this type of set is a method to capture and arrange certain data elements in order to turn data into informationA data set
What are the 2 purposes of Healthcare data sets?1. Identify data elements to be collected on each patient. 2. Provide uniform definitions for common terms.
Why is it important to provide uniform definitions for common terms?It ensures that data collected from a variety of healthcare settings will have a standard definition. (comparing apples to apples and not apples to oranges).
List 2 government oversight commetties in relation to Data Sets in the Electronic Environment.(ONC) Office of the National Coordinator of Health Information Technology. (NCVHS) National Committee on Vital and Health Statistics.

Section 2

Question Answer
The contents of data sets vary by their purpose. However, data sets do not limit what?The number of data elements that can be collected, but the elements will drive what data will be collected. (For benchmarking need to make sure comparing apples to apples).
How is standardization possible regarding data sets?By defining the common formats data elements and their attributes. Having defined data sets ensure consistent data collection and reporting.
Give some examples of what data sets may be used for ?Research - Clinical trials - Quality - Safety improvement - Reimbursement - Accreditation - Exchanging clinical information.
What is the 1st specific type of Data Set?(UHDDS) Uniform Hospital Discharge Data Set
What is the main type of data set HIM will come in contact with, and when was this data first collected?UHDDS - The late 1960's.
What type of information is collected in the first type of data set for UHDDS?Personal identification - Date of birth - Sex - Race and ethnicity - Residence - Discharge date - Total charges - etc.
What is the purpose of the UHDDS?To list and define a set of common, uniform data elements that are collected from the health records of every hospital "Inpatient" and later abstracted from the health record and included in national databases.
Where is UHDDS data sets collected from, who requires this collection, and what is it used in?Short-term general hospitals - Collected from every hospital inpatient - Federal governement - DRGs.
What is the 2nd specific type of Data set?(UACDS) Uniform Ambulatory Care.
What types of facilities collect (UACDS)?Medical and surgical care provided to patients who depart from the facility on the same day they receive care. (Not admitted) Exp: Physicians' offices, Medical clinics, same-day surgery centers, outpatient hospital clinics and diagnostic departments, emergency treatment centers.
What are the 3 reasons for the decrease in inpatient hospitalizations and an increase in ambulatory care visits?1. Technological advancements. (Exp. Davinchi robot gives surgeons another pair of precise hands when operating). 2. Third-party reimbursement for outpatient services. (Most procedures can now be performed on an outpatient basis) 3. Medicare prospective payment (PPS) limits. (This encourages the use of ambulatory and/or outpatient care as an alternative to more costly inpatient services).
Some data elements collected for UACDS are similar to those collected for UHDDS, What are some that are the same?Personal identifies, residence, date of birth, gender, and reace/ethnicity .

Section 3

Question Answer
What is a specific ambulatory care data element and what are two optional data elements?Reason for encounter - Living arrangements, Marital status.
Regarding the collection of UACDS data elements, is this required or recommended by the federal government?It is recommended so most places do collect it.
What is the goal of UACDS?To improve data comparison and it provides uniform definitions that help analyze patterns for care.
What is the 3rd specific type of Data Set?MDS - Minimum Data Set
MDS is used to collect what type of Data?Long-term care (Longer than 30 days), Federally mandated stadard assessment used to collect demoraphic and clinical data on residents in a Medicare and/or Medicaid-certified long-term care facility.
What are the three components of RAI?Minimum Data Set (MDS) Version 3.0 - The Care Area Assessment process (CAA), and the RAI utilization guidelines.
To meet federal requirments, long-term care facilities must complete an assessment on who and when?Every resident at the time of admission and at designated reassessment points throughout the resident's stay.
MED organizes data according to 20 main categories, it is in place to try to protect the patients. What are "some" of the major cata collected in the MDS?Identification information - Hearing, speech, and vision - Cognitive patterns - Mood - Skin conditions - Restraints - behavior, etc.
What is MDS used for?It is more clinical oriented and is so the government has a better awareness of the care that is being delivered). To create resident assessment protocol and to assess resident safety and quality improvement.
What is MDS data set and who is it collected on?It is far more extensive in clinical nature. It is a core set of screening and assessment elements for long term care patients.
What is the 4th specific type of Data set?The Outcomes and Assessment Information Set (OASIS-C).
OASIS-C is used to collect data on what type of patients?Medicare beneficiaries receiving home health receiving services from a Medicare-certified home health agency.
What if OASIS-C used for?Measuring patient outcomes, as a basis for home health reimbursement, and to assess the patient's ability to be discharged or transferred from home care services.

Section 4

Question Answer
List a few catagories data for OASIS-C is grouped into?Patient tracking items - Clinical record items - Patient history and diagnoses - Living arrangements - Medications - Cardiac status - Integumentary status - Sensory status.
What is the 5th specific type of Data set?Healthcare Effectiveness Data and Information Set (HEDIS).
Who sponsers HEDIS and what is it used for?National Committee for Quality Assurance. Used to compare performance of managed healthcare plans. (Benchmarking)
What is HEDIS designed for?To collect administrative, claims, and health record review data. Collects standardized data about specific healt-related conditions or issues so that the success of various treatment plans can be assessed and compared. (Benchmarked)
HEDIS data forms what?The basis of performance improvement (PI) efforts for health plans. Develops physician profiles. Abstracted from health records in hospitals and clinics. Used in benchmarking.
HEDIS contains more than 70 measures related to conditions such as what?Womens issues, Heart disease, cancer, diabetes, asthma, chlamydia infection, osteoporosis, and rheumatoid arthritis.
HEIDS includes data related to what?Data related to patient outcomes and data about the treatment process used by the clinician in treating the patient.
What is the 6th specific type of Data set?Data Elements for Emergency Department Systems (DEEDS).
Starting in 1997, who publised the DEEDS?The centers for Disease Control and Prevention (CDC) through its National Center for Injury Prevention and Control (NCIPC).
What is the purpose of the DEEDS data set?To support uniform collection of data in hospital-based emergency departments.
DEEDS recommends the data set contain ?Contains byth content and structure of data elements collected.
DEEDS recomends the collection of 156 data elements and incorperates what type of standards.National standards for electronic data interchange (EDI).

Section 5

Question Answer
What are the 8 sections DEEDS data is organized in list a few ?Patient identification data - Facility and practitioner identification data - Emergency department payment data - Emergency department arrival and first-assessment data - Emergency department history and physical examination data
In 1997 The Joint Commission (TJC) introduced what?ORYX for benchmarking the different facilities. It is an initiative to integrate outcomes data and other performance measurement data into its accreditation process. (Named after an African animal thought of as a different kind of zebra).
What does the ORYX initiative promote (the goal)?Comprehensive, continuous, data-driven accreditation process.
What is the TJC's primary function?The accreditation of hospitals and other healthcare organizations.
What are the core measures of the ORYX initiative based on?Selected diagnoses/conditiona such as diabetes mellitus, the outcomes of which can be improved by standardizing care.
What do the core measures of the ORYX rely on?Data elements that are readily available or already collected.
Designed to collect a minimum set of data about inpatients?UHDDS
What is used to collect data about ambulatory care patients?UACDS
What is used to collect data about long-term care residents?MDS
Describe the DEEDS data set?Collects data about hospital emergency encounters.
Used to gather data about Medicare beneficiaries receiving home care?OASIS-C

Section 6

Question Answer
Privdes a structured way to develop a long-term care resident care plan?MDS
Set of performance measures used to compare the performance of managed healthcare plans?HEDIS
Developed by the Joint Commission?ORYX
Core data set for a patient's clinical summary?CCR (Continuity of Care Record).
The Resident Assessment Instrument is triggered by the data collected by the?MDS
What are the 6 specific types of data sets.UHDDS - UACDS - RAI and MDS - OASIS-C - HEDIS - DEEDS
UHDDS?Uniform Hospital Discharge Data Set
UACDS?Uniform Ambulatory Care Data Set
RAI - MDS?Resident Assessment Instrument and Minimum Data Set
OASIS-COutcomes and Assessment Information Set
HEDIS Healthcare Effectiveness Data and Information Set
DEEDS Data Elements for Emergency Department Systems

Section 7