10/1/2012hci571 isabelle bichindaritz1 health data concepts

10/1/2012 HCI571 Isabelle Bichindaritz 1

Health Data Concepts

• Define key words.• Define, compare, and contrast data and

information.• Describe the major users of health care data

and the importance of addressing the needs of each.

• Identify the steps in the management decision-making process with particular attention to step 2, the collection of data.

• .

Learning Objectives


• Describe the five unique roles of the health record.

• Discuss the importance of data in the care of the patient

Learning Objectives


• The patient record is the information centerpiece of health care decision-making for:– Individual patient treatment– Potential to collect data for research

• It contains essential data to answer the key questions related to who, what, when, where, why and how of patient care.

Introduction


Who? Who are the patient, the provider and the payer?

What? What services were provided and at what cost?

When? When were the services provided?

Where? Where were the services provided?

Why? Why were the services provided, or what was the justification for the services?

How? How effective were the services, or what was the outcome?

Introduction Essential Health Data and Information

Questions


• Use medical data to:– Understand their health care.– Become more active partners in maintaining or

improving their health.– Monitor care if additional treatment is

necessary.– Document the services received.– Serve as proof of identity or disability.– Verify billed services.

Users and Uses of Health Data Patients


• Treating clinicians (including doctors, nurses, etc.) use the record to communicate with each other.

• At a follow-up facility practitioners use the record:– For continuing care– To develop care plans– To outline important nursing interventions– As a resource



• Health Care Providers and Administrators includes:– Individual practitioners– Hospitals– Outpatient clinics– Long-term care facilities– Home-care agencies– Hospices



• Providers use the data to:– Evaluate care– Monitor the use of resource– Receive payment for services rendered

• Administrators analyze financial and patient case mix information for:– Business planning – Marketing activities



• Include:• Private insurance companies• Managed care organizations• Fiscal intermediaries (who process claims for Medicare and

Medicaid)

• Data are the basis for appropriate payment.• Want to know the services provided for the

dollars spent.• Transaction-based bills are disappearing but data

will still be needed to document services.



• Case management:– Coordinates care so the patient is cared for in most clinically

cost-effective manner.– Emphases disease management.

• Data recorded at the time of care is the basis for:– Review of health care delivery– Performance of quality assessment

• Quality assessment and improvement committees use the info as:– A basis for analysis, study, and evaluation of the quality of

care given to the patient



• Governmental agencies use health care data to determine the appropriate use of governmental financial resources for:– Health care facilities– Educational institutions– Correctional institutions

• Public health is concerned with the overall health of the community– Surveillance, prevention, promotion of healthy

behavior



• Collaborations to move clinical data across various health information systems within a geographical area

• Goal of partner organizations is to provide patient-centered care that improves:– Quality– Safety– Efficiency– Timeliness– Accessibility

• Use common nonproprietary standards for content• Are the building blocks of the U.S. National Health

Information Network (NHIN)

Health Information Exchange


• Attorneys, the Courts, the Judicial Process• Planners and policy developers (State

Health departments)• Educators and trainers• Researchers and epidemiologists• Media reporters• …

Other Users


• Progression:

Data Information Knowledge Wisdom

• Data is gathered:– Consistent with the characteristics of data

quality– Arranged and displayed to add context and

create useful information– Given meaning leading to knowledge– Acted upon with insight to make wise decisions

Decision Making Knowledge Hierarchy


• Data:– a collection of elements on a given subject– the raw facts and figures expressed in text,

numbers, symbols, and images– facts, ideas, or concepts that can be captured,

communicated, and processed– data is plural; datum is the singular

Decision Making


• Information:– Data that have been processed into meaningful form

to make them valuable to a user– Adds context to a representation– Tells the recipient something that was not known

before

• Knowledge:– Information further enhanced with meaning– Explains the how and why about something

Decision Making


• Wisdom:– Places knowledge in a framework to allow it to

be applied in different situations in a measurable way to make wiser decisions and to establish and reach goals

Decision Making


• Steps for effective decision-making:– Problem identification– Data collection and analysis– Development of alternatives– Selection of the best alternative– Action– Follow-up and evaluation

Decision Making


• HIM professionals must:– Consider purpose for data collection– Gather sufficient data items– Resist the desire to collect too much data

Decision Making


• Why collect data?– To satisfy an identified need for the retention,

retrieval, and use of data – To generate meaningful information and knowledge

• Data should be captured once and used by all portions of the system.

• Advances in electronic health records will allow for combination of discrete data and narrative content within records.

Decision Making


• Challenge for HIM manager:– Collecting the necessary data to support and promote the

efficiency and effectiveness on behalf of:• The patient• The provider• The facility• Public health

– Each will use the data differently and will benefit from reliable and consistent definitions of data elements

– Definitions help:• Facilitate data exchange• Reduce misunderstandings

Decision Making


• Five Roles:– It represents the patient’s health history.– It provides a method for clinical communication and care

planning among individual health care practitioners.– It serves as the legal document describing the health care

services provided.– It acts as a source of data for clinical, health services, and

outcomes research – It serves as a major resource for health care practitioner

education.

Overview of the Patient Record The Unique Roles of the Patient Health Record


• It collects data and information.• It generates reports on a single patient.• Is the primary legal record documenting the

health care services provided to a person in the health care system.

• Is generated by practitioners as a result of interaction with the patient and/or those who have personal knowledge of the patient.

Overview of the Patient Record Patient Health Record


• Includes:– Routine clinical or office records– Records of care in a health-related setting– Preventive care– Lifestyle evaluation– Research protocols– Clinical databases

• Contains information about:– The patient– Other individuals as they relate to the patient



• Synonymous with:– Medical record– Health record– Patient care record– Primary patient record– Client record– Resident record



• Record used by health care practitioners:– While providing patient care services– To review patient data– To document observations, actions,

and instructions



• Derived from the primary record• Contains selected data elements• Aids in the support, evaluation, and

advancement of patient care

Overview of the Patient Record Secondary Patient Record


• Patient care support– Administration– Regulation– Payment functions

• Patient care evaluation– Quality assurance– Utilization review– Medical or legal audits

• Patient care advancement– research

Overview of the Patient Record Secondary Patient Record


• The portion of the health record that will be disclosed to parties outside the organization

Overview of the Patient Record Legal Health Record


• A comprehensive patient record compiled and accessible over the individual’s life span from birth to death

• Advantages:– Easy access to medical history– Contains costs by reducing repeated diagnostic testing and

treatments– Promotes patient safety through:

• Medical alerts• Information on:

– Allergies– Drug Reactions– Drug-drug or drug-food interactions

Overview of the Patient Record Longitudinal Health Record


• Paper-based records cannot achieve the advantages because of:– Lack of standardization– Difficulty in organization– Limited access

• Benefit to EHR is the ability to create longitudinal records

Overview of the Patient Record Longitudinal Health Record


Examples of Documentation


• Discharge and Interval Summary– Concise review of the patient’s course– Begins with reason for admission– Standard terminology essential– Includes:

• chronological descriptions of significant findings from examinations, tests, procedures, and therapies

• details regarding discharge• condition on discharge related to condition on admission• follow-up instructions• relevant diagnoses established by the time of discharge• all operative procedures performed


10/1/2012hci571 isabelle bichindaritz1 health data concepts

Documents

health care providers

essential data

importance of data

patient care

medical data

collection of data

contrast data

care plansto