Secondary Data SourcesThe health record’s primary purpos.docx
- 1. Secondary Data Sources The health record’s primary purpose is patient care and reimbursement for encounters. In order to see trends in a population of patients, you look at the data that is extracted from the records and enter it into databases – registries, indexes, etc. These data sources are referred to as secondary data sources. HIM Roles in Managing Secondary Records and DatabasesEstablishing database: Determining content of database Ensuring compliance with laws, regulations, and accreditation standards Data dictionary Data steward: oversees that data put in database or registery is accurate and complete Differences Between Primary and Secondary Data Sources Primary data source: medical record… b/c it contains information about a patient that has been documented by a healthcare professional Secondary data source: data contained in indexes, registries and similar databases Ways to classify data: Patient-specific/identified data Patient identified within the data. Every fact recorded in the
- 2. record relates to a patient by name. Patient identifiable data If identify of patient can be derived or inferred from the data with or without the assistance of a computer. Can the patient be identified by date of birth, phone #, zip code, Aggregate data Data on groups of patients without identifying any particular patient individually Purposes and Users of Secondary Data SourcesFour major purposes to collect secondary data: Quality, performance, and patient safety Research – data entered into databases help researchers determine treatment plans Population health – require information be reported about certain diseases to prevent spreading Administration – facilities are required to check physicians in the national database for information on previous malpractice or action against the physician Internal Users Users within the organization Examples: Medical staff, Management staff Identify patterns and trends that are helpful in patient long term care, benchmarking with other facilities. External users Individuals and institutions outside the facility Examples: State data banks, Federal agencies Federal government collects data from states on vital events like
- 3. births and deaths Types of Secondary Data Sources Facility-specific indexes: enable health records to be located by diagnosis, procedure, physician. Originally kept on cards, now in computerized databases due to technology. Broken down into several types… let’s discuss those types! Master Population /Patient Index (MPI) Disease and Operation Index Physician Index Registries Purpose: to collect data from health records and to make them available for users Registries contains more extensive information than indexes. Index reports created using data from existing facility databases. Registries contain more extensive data from the patient record. Each registry must define the cases that will be included: case definition Case finding used to identify the patients who have been treated in a facility for a particular disease Virtual Field Trip Using Patient Registries to Improve Healthcare Quality http://www.youtube.com/watch?v=_3ZPZ0EKVCE
- 4. Example: Cancer RegistriesFacility-based registries: Provide information for improved understanding of cancer (diagnosis, treatment)Population-based registries: Identifying trends and changes in the new cases of cancer within the area covered by the registry Registry required to collect data such as: Demographic info about each cancer case Occupational history of individual Pathological data about the cancer (site, stage, type of treatment) Example: Data Collection for Immunization RegistriesPatient nameBirth dataSex, race, ethnicityBirth orderBirth state/countryMother’s nameVaccine typeVaccination dateVaccine lot number National Practitioner Data BankDatabase of medical malpractice payments, adverse licensure actions and certain professional review actionsRequired reporting: Information on practitioner The reporting entityPenalties for non-reportingData used in credentialing processhttp://www.npdb-hipdb.hrsa.gov/ Healthcare Integrity and Protection Data BankMandated by HIPAA to report healthcare fraud and abuseFinal adverse actions are reported: Federal or state licensing and certification actions Exclusions from participation in federal or state healthcare programs Any other adjudicated actions or decisions defined in the
- 5. HIPDB regulations Healthcare Cost and Utilization Project (HCUP) Started in 1988 Our most comprehensive source of hospital care data Data collected from these types of encounters: in-patient stays, ambulatory surgery and services visits, and emergency department Includes clinical and nonclinical data (diagnoses and procedures, discharge status, patient demographics, and charges) for all patients, regardless of payer (e.g., Medicare, Medicaid, private insurance, uninsured) Enables researchers, insurers, policymakers and others to study health care delivery and patient outcomes over time Family of databases, software tools and related products Data is used for research on health policy issues: cost and quality of health services medical practice patterns access to health care programs outcomes of treatments at the national, State, and local market levels. Direct quote taken from: https://www.ahrq.gov/research/data/hcup/index.html Healthcare Datasets and Information ManagementVirtual Field Trip: https://www.youtube.com/watch?v=IDM- Vd2iyGg&nohtml5=False