HIT 101 Secondary Data Sets Tech Focused Care Essay

Primary and Secondary Data Sets: The medical record is considered a primary data set. Providers document directly into the record using facts and measurements. These facts and measurements are referred to as data (pl). Each fact/measurement is referred to as a data element. Information is data that has been collected, combined, analyzed, and/or interpreted. Data about patients can be extracted from individual records and combined into aggregate data. The aggregate data is used to develop information about groups of patients. Have you ever seen Carrie Lazarus’s Family Health Cast on Channel 9 News? She often provides information gathered during studies. Many of the studies use aggregated data abstracted or extracted from the patient’s record. If you go to St. Joseph’s Hospital’s website, www.sjhsyr.org/sjhhc/stj_patient_ortho.asp, you will see that they performed 3459 orthopedic surgeries in 2010. To collect this data, they used the extracted data and ran a search known as a query. When information is abstracted for statistical or regulation purposes, a secondary data set is created. A secondary data set can be defined as data taken from the primary health record data sources and entered into registries and databases. The purpose is provide information not easily available by looking through the primary (health record) data source. A secondary data set can be facility based or population based. In this module, we will review both. To compare facilties, it is necessary to collect the same information. To ensure standardization, it is necessary to utilize a data set with specific definitions. HIT 101 Secondary Data Sets Tech Focused Care Essay

The first data set to be established is the hospital discharge data set. The data set allows facilities to abstract information from the individual patient’s record using a data dictionary. A data dictionary is a list of data elements collected in a medical record, the definition for each data element, the attributes of each data element, specifications for the size of the dta field and description of data views to be accessed by the various users. The Uniform Hospital Discharge Data Set (UHDDS) and the Uniform Ambulatory Care Data Set (UACDS) each have established data dictionaries since the 1970’s and 1980’s respectively. However, each both are evolving as technology evolves. Your book gives an example of how the traditional gender element of male and female must be expanded to male, female, undetermined and unknown. Your book has a table outlining the UHDDS data elements in chapter 5. The following link shares information from 1996 when the UHDDS underwent one of its first changes: CDC UHDDS This is going to be a very important document for you to review and to become familar with as all acute care facilities collect and report elements from the UHDDS. Long term care is not excluded from standard collecting of data. The Minimum Data Set (MDS) utilizes may of the same elements from the UHDDS and expands into elements unique to long term or skilled nursing care. Data collected in the MDS is used to develop a Resident Assessment Protocol (RAP). For each triggered RAP, the facility must describe the nature of the condition, complications and risk factors that must be considered for care planning, individual interventions based on the resident’s needs and the need for futher evaluation. The MDS 3.0 was implemented on October 1, 2010 and greatly expanded the number of data elements collected. Today’s healthcare arena has been greatly changed by the increasing use of home health care. The Outcomes Assessment and Information Set (OASIS) gathers information about Medicare patients receiving care from a home health agency. The data is used to assess the quality of services provided and is the basis for reimbursement. We are fortunate to work in an electronic age that facilitates the collection and reporting of data. Many software vendors have specialized in one or two of these data sets and provide facilities with a program to collect information while providing some basic edits and alerts. For example, an abstractor would not be able to add a pregnancy diagnosis code on a male patient or a newborn code would not be allowed on an individual over one year of age. The software programs generally allow the facility to collect and store UHDDS and UACDS data for statistical purposes. The programs are often expanded to include additional information that may be of interest to the facility. For example, a facility may want to collect the date of the last mammography for any patient diagnosed with breast cancer, even if it is a year prior to admission. I know one facility in Vermont use to collect information on education and recent travel experience. Traditionally, information was completed collected on a data sheet with valid answers listed for each data element and sent to a service that would scan or enter the information. The service would then print the information and send it back to facility in paper form for research purposes. When I worked at Community General Hopsital in the late 1980’s, one six month period would fill four 4-inch binders for the diagnosis listing alone. Our technology has definitely improved with facilites now having the ability to query the system for the information needed. The next few lectures will discuss registers and indexes. It is important to remember that these items have been in place long before the UHDDS was established; however, completion of the UHDDS now includes collecting information for the generation of many of the indexes. Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 7: Secondary Data Sources ahima.org ahima.org © 2020 AHIMA Introduction • Databases are used to see trends in data • HIT 101 Secondary Data Sets Tech Focused Care Essay

Facility-specific registry • Population-based registry ahima.org © 2020 AHIMA Roles in Managing Secondary Records and Databases • Establishing database • Determining content of database • Compliance with laws, regulations, and accreditation standards • Data dictionary • Data stewardship ahima.org © 2020 AHIMA Differences Between Primary and Secondary Data Sources and Databases • Primary data source • Secondary data source • Ways to classify data • Patient identifiable data • Aggregate data • Secondary data are usually aggregate data ahima.org © 2020 AHIMA Purposes and Users of Secondary Data Sources • Four major purposes • • • • Quality, performance, and patient safety Research Population health Administration ahima.org © 2020 AHIMA Users of Secondary Data • Internal users • External users ahima.org © 2020 AHIMA Types of Secondary Data Sources • Facility specific indexes • Disease • Operation • Physician ahima.org © 2020 AHIMA Types of Secondary Data Sources • Registries • • • • • • • • Disease Cancer Trauma Birth defect Diabetes Implant Transplant Immunization ahima.org © 2020 AHIMA Cancer Registry • Cancer Registries Amendment Act of 1992 • Case definition • Case finding • Accession registry • Accession number • Staging ahima.org © 2020 AHIMA Cancer Registry Reporting cancer cases Annual report Quality assessment Research Follow-up ahima.org © 2020 AHIMA Cancer Registry • American College of Surgeons Commission on Cancer • North American Association of Central Cancer Registries • Centers for Disease Control and Prevention • National Cancer Registrars Association • Certified Tumor Registrar ahima.org © 2020 AHIMA Trauma Registry • Traumatic injury • Case definition • Case finding • Abbreviated Injury Scale • Injury Severity Score • Annual report • May or may not perform follow-up ahima.org © 2020 AHIMA Birth Defect Registry • Newborns with birth defects • Case definition • Case finding ahima.org © 2020 AHIMA Diabetes Registry • Patients with diabetes • Case definition • Case finding • Follow-up ahima.org © 2020 AHIMA Implant Registries • Implants • Pacemakers • Heart valve • Etc. • Case definition • Case finding • FDA reporting ahima.org © 2020 AHIMA Transplant Registries • Organ transplant • Track patients who need transplant • Track patients who had transplant ahima.org © 2020 AHIMA Immunization Registry • Track immunizations from multiple providers • Remind parents of immunization ahima.org © 2020 AHIMA Other Registries • May be developed for any disease or condition • Cardiovascular diseases • Gastroenterology conditions • Administrative registries may be created • National Provider Identifier Registry ahima.org © 2020 AHIMA Healthcare Databases • National and state administrative databases • Medicare Provider Analysis and Review • Acute care hospital and skilled nursing facility claims data • Medicare patients • Data • • • • • • • ahima.org © 2020 AHIMA 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 • Information on practitioner • The reporting entity • Penalties for nonreporting • Data used in credentialing process ahima.org © 2020 AHIMA National, State, and County Public Health Databases • Public health • Surveillance of health state of population • Monitors • • • • Incidence and prevalence of disease Possible high-risk populations Survival statistics Trends over time • Data collected by interview, physical exams, and health records ahima.org © 2020 AHIMA National Health Care Survey • Public health survey • HIT 101 Secondary Data Sets Tech Focused Care Essay

Made up of multiple surveys • • • • National Hospital Care Survey National Hospital Ambulatory Medical Care Surgery National Ambulatory Care Medical Care Survey National Survey of Long-Term Care Providers ahima.org © 2020 AHIMA Healthcare Databases • National and state administrative databases • National, State, and County Public Health Databases • Other Public Health Databases ahima.org © 2020 AHIMA Other Public Health Databases • National Electronic Disease Surveillance • National Health Interview Survey • National Immunization Survey • State and local databases ahima.org © 2020 AHIMA 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 ahima.org © 2020 AHIMA Clinical Trials • Research project in which new treatments and tests are investigated • Protocols • ClinicalTrials.gov • Information includes summary of purpose of study, recruiting status, criteria for participation, location of trial, and contact information ahima.org © 2020 AHIMA Health Services Research Databases • Research concerning healthcare delivery system • Agency for Healthcare Research and Quality • Healthcare Cost and Utilization Project ahima.org © 2020 AHIMA National Library of Medicine • Medical Literature, Analysis, and Retrieval System Online (MEDLINE) • Biographical listings for publication • Unified Medical Language System (UMLS) • Links between different information systems ahima.org © 2020 AHIMA Health Information Exchange • Patient-specific data • Used for patient care ahima.org © 2020 AHIMA Data for Performance Measurement • Database for core performance measures • Required for Joint Commission, CMS, and some health plans ahima.org © 2020 AHIMA HIM Roles • Collect secondary data • Analyze secondary data • Maintain privacy • Registrar (cancer, immunization, etc.) • Database administrator ahima.org © 2020 AHIMA …