question

EHR health record data entered once and used many times such as: (EHR is a database)

answer

research, improvement in patient care, reported to the state and become part of state and federal level databases used to set health policy and improve healthcare

question

HIM professional roles in managing secondary record and databases include:

answer

determining the content of the database and ensuring compliance with the laws, regulations and accreditation standards that affect its content and use.

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All data elements included in the database or registry must be defined in a:

answer

data dictionary

question

The HIM professional may serve as a __________ to oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry

answer

data steward

question

The health record is considered a __________ data source because it contains information about a patient that has been documented by the professionals who provided care or service to that patient

answer

Primary Data Source

question

Data contained in registries and similar databases are considered a _______________ data source.

answer

Secondary data source

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Other classifications of data

answer

patient-specific/identified data patient identifiable data, or aggregate data

question

What is patient identified data?

answer

where the patient is identified within the data. (health record, registries)

question

data on groups of people or patients without identifying any particular patient individually.

answer

aggregate data

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4 major purposes for secondary data

answer

-Quality, performance and safety CMS measures information from health records to evaluate the quality of care within the facility - Research - data entered into disease oriented databases help to determine the effectiveness of a treatment method and can quickly demonstrate survival rates at different stages - Population health - states require that information be reported to them on certain diseases so that the extent of the disease can be determined and measures to prevent its spread can be initiated. - Administration - Used for credentialing physicians, for malpractice or other adverse decisions against a physician

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A user of secondary data that are individuals located within the healthcare facility

answer

Internal Users of secondary data

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A user of secondary data that are individuals and institutions outside the facility

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External Users of secondary data, state data banks and federal agencies - generally use aggregate data and not patient identifiable data.

question

Bob Smith is a 56 year old white male. This is an example of what type of data?

answer

Patient specific

question

Which of following is an example of how an internal user utilizes secondary data?

answer

Benchmarking with other facilities

question

Secondary data is used for multiple reasons including:

answer

Assisting researchers in determining effectiveness of treatments

question

True or False: A registry is a secondary data source

answer

True

question

True or False: A patient health record contains aggregate data

answer

False

question

True or False: Administrative and management staff members are internal users of secondary data

answer

True

question

True or False: Medical staff members are external users of secondary data

answer

False

question

Secondary data sources consist of facility-specific indexes: such as:

answer

registries, either facility or population based; or other healthcare databases

question

The most long standing secondary source are those that have been developed within facilities to meet their individual needs and are called;

answer

Facility specific Indexes - and provide indexes to enable health records to be located by diagnosis, procedure, or physician

question

MPI contains patient-identifiable data

answer

names, address, date of birth, dates of hospitalizations or encounters, name of attending physician and health record number. Great source for locating the patient record number.

question

A listing in diagnosis code number order of patients discharged from the facility during a particular time period.

answer

disease index and is considered patient identifiable data as it contains the patient's record number and can be linked directly.

question

A listing in numerical order by the patient's procedure code(s) using the International Classification of Diseases or Current Procedural Terminology (CPT) codes.

answer

Operation index and is considered patient identifiable data.

question

A listing of cases in order by physician

answer

physician index and is patient identifiable data

question

Collections of secondary data related to patients with a specific diagnosis, condition, or procedure.

answer

Disease registry - contain more extensive data than indexes. Each registry must define the cases that are to be included in it.

question

Case definition

answer

A registry defining the cases that will be included in the database.

question

Case finding

answer

method used to identify the patients who have been seen and/or treated in the facility for the particular disease or condition of interest to the registry. Some registries collect data from health records to make them available to users

question

Cancer registries: Facility based

answer

provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment. Can provide comparisons in the survival rate with a specific treatment

question

Cancer registries: Population Based (from more than one facility

answer

emphasis is on identifying trends and changes in the incidence (new cases) of cancer within the area covered by the registry

question

Cancer Registries Amendment Act of 1992 provided funding for a national program of cancer registries with population based registries in each state and mandated to collect data such as:

answer

- Demographic info about each case of cancer -Info on the industrial or occupational history of the individuals with the cancers (to the extent such info is available from the same record - Administrative info including date of diagnosis and source of info - Pathological data characterizing the cancer, including site, stage of the neoplasm, incidence, and type of treatment

question

NPCR - National Program of Cancer Registries state registries

answer

developed as a result of Cancer Registries Amendment Act of 1992 - collects population based data - CDC has national standards regarding the completeness, timeliness, and quality of cancer registry data from state registries through the NPCR. CDC collects data from the NPCR state registries

question

Cancer registries - population based

answer

usually depend on hospitals, physician offices, radiation facilities, ambulatory surgery centers (ASC), and pathology laboratories to identify and report cases to the central registry

question

Accession number and Accession registry

answer

number assigned when a case is first entered into the cancer registry and a registry of all cases in accession number order provides a way to ensure that all cases have been entered into the registry.

question

In addition to demographic information, what other data might it include in the cancer registry? (4)

answer

-Type and site of the cancer - Diagnostic methodologies - Treatment methodologies - Stage at the time of diagnosis

question

Collaborative Stage Data Set

answer

The American Joint Committee on Cancer (AJCC) has worked through its Collaborative Stage Task Force with other organizations with staging systems to develop a new standardized staging system.

question

Reporting and Followup for cancer registry data

answer

Formal reporting of cancer registry data is done through an annual report.

question

Education and Certification for Cancer Registrars

answer

NCRA - National Cancer Registrars Assoc has worked with colleges to develop formal edu prog for cancer registrars. Certified Tumor Registrar(CTR) bypassing an examination provided by the National Board for Certification of Registrars (NBCR). Eligibility includes combination of edu and experience

question

Abstracted data for trauma registries include:

answer

-Demographic info on the patient -Info on the injury - Care the patient received before hospitalization (care at another hospital, emts) - Status of the patient at the time of admission - Patient's course in the hospital - Diagnosis and procedure codes -Abbreviated Injury Scale (AIS) - Injury Severity Score (ISS)

question

The Safe Medical Devices Act of 1990 and amended in 1992

answer

require a sample of facilities to report death and severe complications thought to be due to a device to the manufacturer and the Food and Drug Administration through its MedWatch reporting system.

question

MedWatch Reporting System

answer

alerts health professionals and the public of safety alerts and medical device recalls.

question

The FDA requires that all reportable events involving medical devices include the following information

answer

-User facility report number -Name and address of the device mfg - Device brand name and common name - Product model, catalog, serial, and lot numbers - Brief description of the event reported to the manufacturer and/or the FDA - Where the report was submitted (to FDA, manufacturer, or distributor)

question

Only gastroenterology registry sponsored by the CMS enabling practices to directly submit data for the CMS Physician Quality Reporting System.

answer

American Gastroenterological Association Digestive Health Outcomes Registry

question

Registries developed for admin purposes

answer

National Provider Identifier Registry and enables users to search for a provider's national provider identification number.

question

HIPPA mandated the collection of info on healthcare fraud and abuse because there was no central place to obtain this info.

answer

national Healthcare Integrity and Protection Data Bank (HIPDB) was developed

question

the area of healthcare dealing with the health of populations in geographic areas such as states or counties.

answer

Public Health - National Center for Health Statistics has resposibility for these databases

question

CDC developed the National Electronic Disease Surveillance System (NEDSS) that serves as a major part of the Public Health Info Network (PHIN)

answer

provides a national surveillance system by connecting the CDC with local and state public health partners to monitor trends from disease reporting at the local and state levels to look for possible bioterrorism incidents

question

collection of vital statistics rests with:

answer

the states

question

research project in which new treatments and tests are investigated to determine whether they are safe and effective

answer

clinical trial - proceed according to protocols (lists of rules and procedures to be followed)

question

FDA Modernization Act of 1997 mandated that a clinical trials database be developed - it is called:

answer

National Library of Medicine has developed the database which is available online for use by both patients and practitioners

question

4 study phases of a clinical trail

answer

Phase 1 studies research the safety of the treatment in a small group of people. Phase 2 studies, emphasis is on determining the treatment's effectiveness and further investigating safety. Phase III studies look at effectiveness and side effects and make comparisons to other available treatments in larger populations. Phase IV studies look at the treatment after it has entered the market.

question

research concerning healthcare delivery systems, including organization and delivery and care effectiveness and efficiency. Within the federal gov who is the org most involved in health services research?

answer

Health services research; Agency for Healthcare Research and Quality (AHRQ) who's major initiative has been the Healthcare Cost and Utilization Project (HCUP)

question

The National Library of Medicine (NLM) produces two databases of special interest to the HIM manager:

answer

MEDLINE, and UMLS

question

MEDLINE Medical Literature, Analysis, and Retrieval System Online

answer

best known database from the NLM and includes bibliographic listings for publications in the areas of medicine, dentistry, nursing, pharmacy, allied health, and veterinary medicine. HIM mgrs use MEDLINE to locate articles on improvement and medical research activities.

question

UMLS - Unified Medical Language System

answer

provides a way to integrate biomedical concepts from a variety of sources to show their relationships. process allows links to be made between different info systems for purposes such as electronic health record systems. Specific interest to HIM mgr is medical vocabularies such as the ICD-9-CM, CPT, and the HCPCS are among the items included.

question

HIE - Health Information Exchange

answer

initiatives have been developed to move toward a longitudinal patient record with complete information about the patient available at the point of care. Patient specific info rather than aggregate data used primarily for patient care

question

The Joint Commission, CMS and some health plans require healthcare facilities to collect data on core performance measures

answer

secondary data taken from patient medical records

question

Which index is an important source of patient health record numbers?

answer

Master Patient Index (MPI)

question

After the types of cases to be included in a registry have been determined, what is the next step in data acquisition?

answer

Case finding

question

What number is assigned to when it is first entered in a cancer registry?

answer

Accession number

question

What are the patient data such as name, age, address, and so on called?

answer

Demographic data

question

What type of registry maintains a database on patients injured by an external physical force

answer

Trauma registry

question

Why is the MEDPAR File limited in terms of being used for research purposes?

answer

It only contains Medicare patients

question

Which of the following acts mandated establishment of the National Practitioner Data Bank

answer

Healthcare Quality Improvement Act 1986

question

I started work today on a clinical trial. I need to familiarize myself with the rules and procedures to be followed. This info is called the:

answer

Protocol

question

An advantage of HCUP is that it:

answer

Contains data on all payer types

question

Issues surrounding the processing and maintenance of secondary databases

answer

-manual versus automated methods of data collection -Vendor systems versus facility-specific systems -Data stewardship issues associated w/secondary data collection and use - data quality issues -Accuracy, consistency, comprehensiveness, timeliness and confidentiality of the data

question

a responsibility guided by principles and practices, to ensure the knowledgeable and appropriate use of data derived from individual's personal health information and encompasses the concepts of data quality, security, confidentiality, and uniformity.

answer

data stewardship

question

What factors are addressed when assessing data Quality

answer

-data accuracy - data consistency - data completeness -data timeliness

question

What is data accuracy often referred to as

answer

data validity means that the data is correct

question

What methods may be used to ensure validity (accuracy)

answer

-incorporate edits in the database (check on the accuracy of the data) - field comparisons (ie prostrate cancer with Male)

question

What is data consistency often referred to as;

answer

data reliability - complete data checks by having two people abstract data then compare the two results to identify discrepancies - called interrater reliability method of checking

question

Comprehensiveness aka completeness

answer

to avoid missing data, the database can be set so that if one field is not answered they cannot go to the next.

question

Data timeliness

answer

healthcare data should be up to date.

question

Data confidentiality

answer

usually refers to efforts to guarantee the privacy of personal health information

question

HIPPA regulations for privacy regarding registries

answer

For HIPPA covered entities, the data collection done by registries is considered part of "healthcare operations". Therefore the patient does not have to sign an authorization for release of protected health information (PHI) to be included in the registry.

question

No ROI from patient required for:

answer

-entry into a registry - reporting notifiable diseases to the state - data released to internal users, such as physicians for research -External such as American College of Surgeons collect aggregate data

question

Notice of Privacy Practices

answer

Info about patients that may be included in registries or other secondary data sources and reported to outside entities must be included in the facility's Notice of Privacy Practices given to patients on their initial encounters

question

Entities not covered by HIPAA

answer

Not all registries and databases are covered under HIPAA if the organization maintaining them does not bill for patient care services. Central registries would be an example. In such cases, the general norms for data confidentiality should be followed.

question

How do you ensure data definitions and standards are uniform

answer

A data dictionary in which asll data elements are defined helps ensure that uniform data definitions are being followed.

question

Who owns the data both primary and secondary?

answer

In the past, with the primary data source - the patient health record - the consensus was that the facility owned the patient record while the patient controlled its use. This consensus has broken down with extensive use of data from the primary data source in secondary data banks that were unknown to patients, much less under their control.

question

Who owns the data both primary and secondary

answer

Emphasis has switched to the rights of stakeholders regarding access, use and control of both primary and secondary data

question

Who is a stakeholder

answer

some who is affected by an issue. Main stakeholders are patients and providers, also including research and governments.

question

Patients rights to data

answer

Patients must be informed that they do not have exclusive ownership of their information but have the right to know what is collected about them and what uses are made of the data. Providers must be aware that patients have rights regarding their patient records to access what is collected about them as well as to amend or correct erroneous info. Patients have a limited right to determine who has access to their primary data - limited by laws and regulations allowing access to data by governments, researchers and other legitimate users of the data.

question

Using uniform terminology is a way to improve

answer

Data reliability

question

True or False: HIM professionals have worked with many data stewardship issues for years.

answer

True

question

What is used to check the quality of data entered into an information system?

answer

Edits

question

True or False: Now that registries and databases are almost universally electronic, data collection is done manually

answer

False

question

True or False: One advantage to a vendor system is that purchasers can find out about the system's performance from other users

answer

True

question

True or False: With regard to data quality, validity refers to the consistency of the data

answer

False

question

True or false: Among the HIM professional's traditional roles is that of maintaining the confidentiality of health data

answer

True

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