Chapter 2 Health Care Data Quality – Flashcards
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Data
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Characters, words, symbols, measurements..stats
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Information
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Is processed data
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Knowledge
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A combination of rules, relationships, ideas and experience
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Processing
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(1) Healthcare Data (2) Healthcare Information and (3) Healthcare Knowledge
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Medical Records Institutes (MRI)
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Professional organization dedicated to the improvement of patient records through 5 major functions: (1) Patient Safety (2) Public Safety (3) Continuity of Patient Care (4) Healthcare Economics and (5) Clinical research and outcomes analysis
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Information Capture
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Process of recording representatives of human thought, perceptions, or actions in documenting patient care as well as device generated information.
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Report Generation
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Process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record.
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Data Standards
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Must be set to ensure high quality. ie. margin of error must be zero for critical lab tests to ensure patient safety is not in jeopardy.
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Medical Records Institutes (MRI)
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Published "Essential Principles of Healthcare Documentation"
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American Heart Info Management Association (AHIMA)
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Data Quality Model Characteristics: (1) Accuracy (2) Accessibility (3) Comprehensiveness (4) Consistency (5) Currency (6) Definition (7) Granularity (8) Precision (9) Relevancy (10) Timeliness
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Data Accuracy
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Data that reflect correct, valid values are accurate ie. misspelled names
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Data Accessibility
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Data that are not available to the decision makers needing them are of no use
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Data Comprehensiveness
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All of the data required for a particular use must be present and available to the user.
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Data Consistency
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Quality data are consistent ie. an abbreviation with two meanings
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Data Currency
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Many times the admitting dx is not the same as the one recorded upon d/c
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Data Definition
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Clear definitions of data elements must be provided so that both current and future data users will understand what the data mean.
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Data Granularity
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"automicity" cannot be further subdivided
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Data Precision
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How close to an actual size, weight, or other standard a particular measurement is
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Data Relevancy
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Data must be relevant to the purpose for which they are collected
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Data Timeliness
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ie. critical lab values must be available to the health care provider in a timely manner
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Error Types
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[1] Systemic and [2] Random
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Systemic Error
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Results from incorrect programming of the encoding software OR improper training of the individuals assigning the code ie. unclear data definitions, lack of sufficient data checks, poor interface and programming errors
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Random Error
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Results of poor handwriting or transcripting due to carelessness ie. illegible handwriting in data source, typing errors, and lack of motivation
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Government Accountability Office (GAO)
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Found that many of the data in existing EMR systems were recorded in an unstructured format ie. narrative rather than in data fields designated to contain specific pieces of information
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AHIMA Data Quality Management Model
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[Application] the purpose for which the data are collected [Collection] the processes by which data elements are accumulated [Warehousing] processes and systems used to archive data and data journals and [Analysis] the process of translating data into information utilized for an application
