Transcript Chapter 7 - CM

Health Information Management
Technology: An Applied Approach
Chapter 7 Secondary Data Sources
© 2016
Introduction
• Databases are used to see trends in data
• Facility-specific registry
• Population-based registry
Roles in Managing Secondary Records
and Databases
• Establishing database
o Determining content of database
o Compliance with laws, regulations, and
accreditation standards
o Data dictionary
o Data stewardship
Differences Between Primary and
Secondary Data Sources and Databases
• Primary data source
• Secondary data source
• Ways to classify data
o Patient identifiable data
o Aggregate data
• Secondary data are usually aggregate data
Purposes and Users of Secondary Data
Sources
• Four major purposes
o Quality, performance, and patient safety
o Research
o Population health
o Administration
Internal Users
• Users within the organization
o Medical staff
o Management staff
External users
• Individuals and institutions outside the facility
o State data banks
o Federal agencies
Types of Secondary Data Sources
• Facility-specific indexes
o Disease
o Operation
o Physician
Disease and Operation Index
• Disease
o Listing in diagnosis code number order
• Patients discharged during specified period
• Contains
o Health record number
o Diagnosis codes
o Attending physicians name
o Date of discharge
Disease and Operation Index
• Operation
o Similar to disease index
o Numerical order by procedure code
o May also include surgeon’s name
Physician Index
• Listing of cases in order by physician name or
number
Registries
• Disease registries
o Secondary data related to patients with specific
diagnosis, condition, or procedure
o Contain more information than index
o Case definition
o Case finding
Terminology Associated with Registries
• Accession number
o Made up of year and sequential number
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Accession registry
Demographic information
Facility-based registries
Incident
Population-based registry
Cancer Registries
• Facility-based
o Provide information for improved understanding
of cancer
• Population-based registries
o Identifying trends and changes in the incidence of
cases
Cancer Registries Amendment Act of
1992
• Mandated population-based registries in each
state
• Data to be collected include:
o Demographic data
o Industrial or occupational history
o Administrative information including date of diagnosis
and source of information
o Pathological data including site, stage incidence, and
type of treatment
Case Definition and Case Finding in the
Cancer Registry
• Case definition
o Define cases to be entered in registry
o Example: All cancers except skin
• Case findings
o Identify cases that meet case definition
o Examples:
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Discharge process
Disease indexes
Pathology reports
Radiation therapy or other cancer treatment
• Population-based registries rely on hospitals, physician
offices, and other healthcare facilities to identify cases
Data Collection for the Cancer Registry
• Accession number
o Made up of year and sequential number
• Accession registry
• Demographic information
• Information on cancer
o Type and site of the cancer
o Diagnostic methodologies
o Treatment methodologies
o Stage at time of diagnosis
Staging
• Size and extent of spread of tumor
• Staging system developed by American Joint
Committee on Cancer
• Collaborative Stage Data
o Population-based registry
• Usually collects information at time of diagnosis
• Occasionally receives follow-up information
Reporting and Follow-up for Cancer
Registry Data
• Annual report
o Aggregate data on number of cases in past year by
site and type of cancer
• Data used in quality assessment and research
• Patient follow-up
o Obtain information on each patient in registry
Follow-up Methods
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Hospital records
Physician
Contacting patients or relatives
Newspaper obituaries
Social Security Death Index
Reporting and Follow-up for Cancer
Registry Data
• Population-based registry
o Usually does not collect follow-up data
Standards and Approval Processes for
Cancer Registries
• American College of Surgeons Commission on
Cancer
o Requires cancer registry
o Cancer Program Standards
• North American Association of Central Cancer
Registries
o State population registries
Standards and Approval Processes for
Cancer Registries
• Centers for Disease Control and Prevention
o National Program on Cancer Registries
• National standards on completeness, timeliness, and
quality of cancer registries in state registries
Education and Certification for Cancer
Registries
• National Cancer Registrars Association
o Standards for formal education programs
• Certified Tumor Registrar (CTR)
Trauma Registries
• Traumatic injuries
• Data used for performance improvement and
research
• Case definition and case finding for trauma
registries
o Usually involves trauma diagnosis codes
Data Collection for Trauma Registries
• Data elements may include:
o Demographics
o Information on injury
o Care received before hospitalization
o Status of patient at time of admission
o Patient’s course in the hospital
o Diagnosis and procedure codes
o Abbreviated Injury Scale
o Injury Severity Scale
Reporting and Follow-up for Trauma
Registries
• Reporting varies by registries
o Annual report
o Performance improvement process
o National trauma data bank
• May or may not perform follow-up
o Focus is quality of life
Standards and Approval Process for
Trauma Registries
• American College of Surgeons
• Trauma registry required for level I trauma
center
Education and Approval Process of
Trauma Registrars
• May be:
o Registered Health Information Technician (RHIT)
o Registered Health Information Administrator (RHIA)
o Registered Nurse
o Licensed Practice Nurse
o Emergency Medical Technician
• Training is workshops and on the job training
• Certified Specialist in Trauma Registry (CSTR)
Birth Defects Registries
• Collect information on newborns with birth
defects
• Usually population based
• Provide information on incidence of birth
defects and monitor trends
• Case definition
o Varies by facility
o May be limited to those found in first year of life
Birth Defects Registries
• Detected by
o Disease indexes
o Labor and delivery logs
o Pathology reports
o Autopsy reports
o Ultrasound reports
o Cytogenetic reports
o Vital records
Data Collection for Birth Defects
Registries
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Demographic information
Diagnosis codes
Birth weight
Status at birth (liveborn)
Autopsy
Cytogenetics results
Single or multiple birth
Mother’s use of alcohol, tobacco, or illicit drugs
Father’s use of drugs and alcohol
Family history of birth defects
Diabetes Registries
• Used in managing care and research
• Case definition
o May be limited by type of diabetes
• Case findings
o Diagnosis codes
o Billing data
o Medication lists
o Physician identification
o Health plans
Diabetes Registries
• May be found in hospital or physician office
• Data collection
o Demographic information
o Laboratory values
o May track patients
• Reporting and follow-up
o Laboratory monitoring
o Track patients not seen in one year
Diabetes Registries
• Population-based registries
o Incidence
• Purpose of follow-up is to prevent
complications
Implant Registry
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Tracks performance of implants
Safe Medical Devices Act of 1990
Medical Device Amendments of 1992
Must report deaths and severe complications
Case definition
o May be all implants or a specified type
Implant Registry Data Collection
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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
manufacturer or the FDA
• Where report was submitted
Reporting and Follow-up for Implant
Registries
• Reporting to FDA and manufacturer
• Follow-up used to track performance of
implant
• If patients are tracked, they can be notified of:
o Product failures
o Recalls
o Upgrades
Transplant Registry
• May track who needs an organ
o United Network for Organ Sharing
o National Marrow Donor Program
• Data may be used for:
o Research
o Policy analysis
o Quality control
Transplant Registry
• Case definition and case finding for transplant
registries
o Patients who need transplants
• Data collection for transplant registries
o Type of data varies
Pre-transplant Data
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Demographic data
Diagnosis
Status codes regarding medical urgency
Functional status
If patient is on life support
Previous transplants
Histocompatibility
Information on Donor: Death
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Cause and circumstance of death
Organ procurement and consent process
Medications the donor was taking
Other donor history
Information on Donor: Living
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Relationship to donor to recipient (if any)
Clinical information
Information on organ recovery
Histocompatibility
Reporting and Follow-up for Transplant
Registries
• Reporting
o Information on donors and recipients
o Survival rates
o Length of time on waiting list
o Death rates
Reporting and Follow-up for Transplant
Registries
• Follow-up
o Collected on donor and living donors
o Status on follow-up
o Functional status
o Graft status
o Treatment
o Immunosuppressive drugs
Immunization Registries
• Purpose is to increase number of infants and
children to receive required immunizations at
the proper intervals
• Case definition
o All children in population area
• Case finding
o Frequently entered in registry at birth
Data Collection for Immunization
Registries
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Patient name
Birth data
Sex, race, ethnicity
Birth order
Birth state and country
Mother’s name (first, middle, last, and maiden)
Vaccine type
Vaccination date
Vaccine lot number
Reporting and Follow-up for
Immunization Registries
• Reporting
o Immunization rates
• Follow-up
o Reminding parents that it is time for immunization
o Autodialing systems
Standards and Approval Processes for
Immunization Registrations
• CDC’s National Immunization Program funds
some population based immunization
registries
• Functional standards include:
o Establish registry record within 6 weeks of birth
o Protecting confidentiality
o Official immunization records
o Healthy People 2020
Other Registries
• May be developed for any disease or
condition
o Cardiovascular diseases
o Gastroenterology conditions
• Administrative registries may be created
o National Provider Identifier Registry
Healthcare Databases
• National and state administrative databases
o Medicare Provider Analysis and Review
• Acute care hospital and skilled nursing facility claims data
• Medicare patients
• Data
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Demographic data
Data on provider
Information on Medicare coverage
Total charges
Charges by service
ICD diagnosis and procedure codes
MS-DRGs
National Practitioner Data Bank
• Database of medical malpractice payments,
adverse licensure actions, and certain
professional review actions
• Required reporting
o Information on practitioner
o The reporting entity
• Penalties for non-reporting
• Data used in credentialing process
National, State, and County Public
Health Databases
• Public health
o Surveillance of health state of population
o Monitors
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Incidence and prevalence of disease
Possible high-risk populations
Survival statistics
Trends over time
o Data collected by interview, physical exams, and
health records
National Health Care Survey
• Public health survey
• Made up of multiple surveys
o National Hospital Care Survey
o National Survey of Ambulatory Care
o National Nursing Home Survey
o National Home and Hospice Care Survey
• Uses health record data
Other Public Health Databases
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National Electronic Disease Surveillance
National Health Interview Survey
National Immunization Survey
State and local databases
Vital Statistics
• Data on births, deaths, fetal deaths,
marriages, and divorces
• Collected by state
• Information shared with National Center for
Health Statistics
• Linked Birth and Infant Death Data Set
Clinical Trials
• Research project in which new treatments and
tests are investigated
• Protocols
• ClinicalTrials.gov
o Information includes summary of purpose of
study, recruiting status, criteria for participation,
location of trial, and contact information
Health Services Research Databases
• Research concerning healthcare delivery
system
• Agency for Healthcare Research and Quality
o Healthcare Cost and Utilization Project
National Library of Medicine
• Medical Literature, Analysis, and Retrieval
System Online (MEDLINE)
o Biographical listings for publication
• Unified Medical Language System (UMLS)
o Links between different information systems
Health Information Exchange
• Patient-specific data
• Used for patient care
Data for Performance Measurement
• Database for core performance measures
o Required for Joint Commission, CMS, and some
health plans