HIM-Chapter 8

creativity's version from 2015-07-15 20:24

Section 1

Question Answer
Primary DataPatient health record - contains info about a patient that has been documented by the professionals who provided care or services to that patient.
Secondary DataData contained in registries and similar databases. - usually aggregate data.
Data StewardOversees the completeness and accuaracy of the data abstracted for inclusion in the database or registry. (Secondary data source)
Patient-specific/identified dataThe patient is identified within the data
Facility-Specific Indexes locate health records how?By diagnosis, procedure, or physician.
Internal users of secondary data?individuals located within healthcare facility. (i.e. medical staff and administrative staff).
Internal users of secondary data may use it how?Identify patterns and trends helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities.
External users of secondary data?Individuals and institutions outside the facility. (i.e. state data banks and federal agencies)
External users of secondary data may use it how?State data bases on infectious diseases, births, and deaths.
Disease Registry are different from indexes how?They contain more extensive data and may require more extensive entry of data from the patient record.
Disease registries define ?What is going to be in the case, definition locate cases, and cases findings.

Section 2

Question Answer
4 major purposes (main reasons) for collecting secondary data?Quality, performance, and patient safety (collecting for CMS) - Research - Population health (exp. CDC, Health Dept.) - Administration (Physician credentialing).
4 Types of Facility-Specific Indexes?MPI (Master Population/Patient Index) contains paient-identifiable data - Disease index (listing diagnosis code number or discharged data) - Operation index (arranged in numerical order by patient's procedure code) - Physician Index (cases in order by physician name or physician identification number).
3 Types of secondary data sources?Facility-Specific Indexes - Registries (Disease) - Healthcare databases.
What are the 5 Data Quality Issues?Accuarcy of the data - Consistency of the data - Comprehensiveness of the data - Timeliness of the data - Confidentiality of the data.
List some of the different types of registries?Cancer - Trauma - Birth Defects - Diabetes - Implant - Transplant - Immunization
What are the 2 steps regarding disease registry and data acquisition?Case definition - Case finding.
Case definition registry would include?Who will and who will not be included in the registry. (i.e. Trauma registry might include all patients admitted with a diagnosis code into the International Classification of Diseases trauma diagnosis codes).
Case finding is?Method used to identify those patients treated at a facility for a particular disease or condition of interest to the registry.
The cancer registry data can be either ______ or ________.Facility-based registry / Population-based registry.
ACS (American College of Surgeons) Commission 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.

Section 3

Question Answer
Cancer facility-based registries are used how?To provide information for the improved understanding of cancer, including its causes and methods of dianosis and treatment.
Cancer population-based registries emphasis what?Identifying trends and changes in the incidence (new cases) of cancer within the area covered by the registry.
What is an accession number?A number when a cancer case is first entered into the cancer registry.
What is an accession registry?All cancer cases kept manually or reported by database software.
In addition to demographic information in a cancer registry what additional patient information should be included?Type and site of the cancer - Diagnostic methodologies - Treatment methodologies - Stage at the time of diagnosis.
Besides the ACS, what other organization has some oversight over the cancer registires?NAACCR (North American Association of Central Cancer Registries).
Trauma RegistriesTramatic injury - AIS (Abbreviated injury scale) and ISS (Injury Severity Score)
AISScale that assesses the injury and the threat to life of that injury. The higher the number the worse the injury
ISSOverall injury scale (i.e. fair, critical, etc.)
Birth Defects RegistriesCollect information about birth defects.

Section 4

Question Answer
What things in birth defects registries may be unique to this type of registry?Mother's use of alcohol, tobacco, or illicit drugs. Father's use of drugs and alcohol. Family history of birth defects. If infant was a single birth or one in a multiple birth. Status at birth (live born, still born, aborted).
Diabetes Registries are used how?In manageing care and research for diabetes patients. May be limited by type of diabetes (i.e. type I or type II)
Where might you find a diabetes registry?Hospital or physician office.
What data might be collected in a diabetes registry?Demographic info, laboratory values, may track patients to ensure follow-up to prevent complications..
What data collection may be included in Implant registries.user facility report number - name and address of device manufacturer - device brand name and common name - product model, catalog, serial, and lot numbers - brief description of the event reported to manufacturere and/or FDA - Where report was submitted.
What is MedWatch?The FDA through this reporting system alerts health professionals and the public of safety alerts and medical device recalls.
Name the 2 national transplant registries.UNOS (United Network for Organ Sharing), NMDP (National Marrow Donor Program).
What is histocompatibility?Compatability of the donor and receipient tissues.
What is the purpose of immunization registries?Increasing the number of infants and children who receive the required immunizations at the proper intervals.
The National Immunization program at the CDC works with what committee to develop a core set of immunization data elements to be included in all immunization registries?NVAC (National Vaccine Advisory Committee).

Section 5

Question Answer
What is the 1st type of secondary data sources?Facility-Specific Indexes.
What is the 2nd type of secondary data sources?Disease Registries
What are the 3rd type of secondary data sources?Healthcare databases (Some national, i.e. CDC and some state, i.e. State Health Dept.).
Healthcare databases are _____ in nature and very easy to sort. (i.e. sort by provider, zip code, ICD-9 or 10).Administrative
This Healthcare database is for medicare patients only.MEDPAR - Medicare provider analysis and review file. Made up of acute care hospital and skilled nursing facility claims data for all medicare claims.
This Health care data bank was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments.NPDB - National Practitioner Data Bank.
HIPAA mandated the collection of information on healthcare fraud and abuse because there was no central place to obtain this information. This data bank contains that information.HIPDB - Healthcare Integrity and Protection Data Bank.
Public Health is the area of healthcare dealing with what?Health of populations in geographic areas such as states or countries.
What is the database at the national level responsible for health record databases?National Center for Health Statistices.
What type of information would you find in vital statistics database?Births, deaths, fetal deaths, marriages and divorces.

Section 6

Question Answer
This database was mandated by the FDA and developed for clinical trials, who developed this database?The National Library of Medicine.
What is a clinical trial?A research project in which new treatments and tests are investigated to determine whether they are safe and effective.
This agency looks at issures related to the efficiency and effectiveness of the healthcare delivery systems, disease protocols, and guidelines for improved disease outcomes?AHRQ (Agency for Healthcare Research and Quality)
What was a major initiative for AHRQ?HCUP (Healthcare Cost and Utilization Project).
HCUP uses data collected at the state level from either ? claims data or discharge abstracted data, including the UHDDS items reported by individual hospitals and, in some cases, by freestanding ambulatory care centers.
The National Library of Medicine produces two databases of special interest to the HIM manager, what are they?MEDLINE (Medical Literature, Analysis, and Retrival System Online) and UMLS (Unified Medical Language System).
What type of information is included in MEDLINE?Bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and vetinary medicine.
What are some challenges that came with data stewardship in using and maintaining secondary data bases?Clear guideance about ownership of secondary data, unauthorized reuse of data, and spotty confidentiality and security regulations.
What is data stewardship?A responsibility , guided by principles and practices, to ensure the knowledgeable and appropriate use of data derived from individuals personal health information.
What is Interrator reliability?Two or more different people may be used to do the same thing. (i.e. checking behind each other to make sure everything is correct).

Section 7

Question Answer
Accuracy of the data deals with?Validity of the data - correct and accurate use of edits.
Consistency of the data deals with?Reliability - might employ interrator reliability.
What is comprehensiveness of the data?Also referred to as completeness. Used to avoid missing data.
What is Timeliness of the data?The healthcare data should be up-to-date.
What does data confidentiality deal with?Guaranteeing the privacey of personal health information - HIPAA covered entities.
What is a stakeholder?Someone who is affected by an issue.
Who are the main stakeholders in the field of health data?Patients and providers.
What does it mean to be transparent when working with secondary data?Refers to the degree to which patients included in secondary data sets are aware of their inclusion.
An example of how an internal user utilizes secondary data would be what?Benchmarking with other facilities
Assiting researchers in determing effectivness of treatments is an example of what type of data?Secondary
This refers to the degree to which patient included in secondary data sets are aware of their inclusion?Transparency

Section 8

Question Answer
Administrative and management staff members are what type of secondary data users?internal
This type of index is an important source of patient health record numbers?MPI (Mater Patient Index)
After the types of cases to be included in a registry have been determined, what is the next step in data acquisition?Case finding
What number is assigned to a case when it is first entered in a cancer registry?Accession number
What are the patient data such as name, age, address, and so on called?Demographic data
What type of registry maintains a database on patients injured by an external physical force?Trauma registry
Why is MEDPAR file limited in terms of being used for research purposes?it only contains Medicare patients.
This mandated establishment of the National Practioner Data Bank?The Health Care Quality Improvement Act of 1986.
What is the organization most involved in health services research?AHRG (Agency for Helathcare Research and Quality).
What is an advantage of HCUP (Healthcare Cost and Utilization Project)?It contains data on all payer types.

Section 9

Question Answer
Using uniform terminology is a way to improve what?Data reliability
What skills are important for HIM professionals to migrate from paper to the electronic environment to maintain their leadership associated with secondary data collection and use?Data Stewardship
What is used to check the quality of data entered into an information system?Edits
What is an important tenet in quality of secondary data?The quality of the primary data source. The patient health record often contains inconsistencies and errors that can lead to data quality issues in secondary data.
What is an advantage to a vendor system?Purchasers can find out about the system's performance from other users.
With regard to data quality, validity refers to what?The accuarcy, or correctness of the data
With regard to data quality, consistency refers to what?Reliability of data, and is refrequently checked by having more than one person abstract data for the same case.
With regard to data quality, timeliness of data refers to what?Data must be available within a time frame helpful to the user. The healthcare data is up-to-date.
With regard to data quality, comprehensiveness refers to what?Completeness, All useful data is available for research or clinical decision making.
When results are compared to identify any discrepancies by more than one person, this method of checking is referred to as what?Interrater reliability