Posted: November 8th, 2022
Healthcare Informatics Discussion Assignment Paper
Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. chapter 14 Secondary Records and Healthcare Databases Marcia Y. Sharp, EdD, RHIA Learning Objectives ●● Distinguish between primary and secondary data and between patient-identifiable and aggregate data ●● Distinguish among healthcare databases in terms of purpose and content ●● Identify the internal and external users of secondary data ●● ●● Compare the facility-specific indexes commonly found in hospitals Compare manual and automated methods of data collection and vendor systems with facility-specific systems ●● Describe the registries used in hospitals according to purpose, methods of case definition and case finding, data collection methods, reporting and follow up, and pertinent laws and regulations affecting registry operations ●● Assess data quality issues in secondary records ●● Recognize appropriate methods for ensuring data security and the confidentiality of secondary records ●● Discuss some of the other issues related to the collection and maintenance of secondary data such as transparency, ownership, and deidentification ●● Identify the role of the health information management professional in creating and maintaining secondary records ●● Define the terms pertinent to each type of secondary record or database ●● Healthcare Informatics Discussion Assignment Paper
Discuss agencies for approval and education and certification for cancer, immunization, trauma, birth defects, diabetes, implant, transplant, and immunization registries Key Terms Abbreviated Injury Scale (AIS) Abstracting Accession number Accession registry Activities of daily living (ADLs) Agency for Healthcare Research and Quality (AHRQ) Aggregate data Autodialing system Case definition Case finding Claim Clinical trial Collaborative Stage Data Set Computer virus Credentialing Data confidentiality Data dictionary Data security Database Deidentification Demographic information Disease index Disease registry Edit Encryption Facility-based registry 367 15_AB103311_ch14.indd EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 367 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 368 Chapter 14 Food and Drug Administration (FDA) Health services research Healthcare Cost and Utilization Project (HCUP) Healthcare Integrity and Protection Data Bank (HIPDB) Histocompatibility Incidence Index Injury Severity Score (ISS) Interrater reliability Master population/patient index (MPI) Medical Literature, Analysis, and Retrieval System Online (MEDLINE) Medicare Provider Analysis and Review (MEDPAR) National Center for Health Statistics (NCHS) National Health Care Survey National Practitioner Data Bank (NPDB)Healthcare Informatics Discussion Assignment Paper
National Vaccine Advisory Committee (NVAC) Operation index Patient-identifiable data Physician index Population-based registry Primary data source Protocol Public health Registry Secondary data source Staging system Transparency Traumatic injury Unified Medical Language System (UMLS) Vital statistics As a rich source of data about an individual patient, the health record fulfills the uses of patient care and reimbursement for individual encounters. However, it is not easy to see trends in a population of patients by looking at individual records. For this purpose, data must be extracted from individual records and entered into specialized databases that support analysis across individual records. These data may be used in a facility-specific or population-based registry for research and improvement in patient care. In addition, they may be reported to the state and become part of state- and federal-level databases that are used to set health policy and improve healthcare. The health information management (HIM) professional can play a variety of roles in managing secondary records and databases. He or she plays a key role in helping to set up databases. This task includes determining the content of the database or registry and ensuring compliance with the laws, regulations, and accrediting standards that affect the content and use of the registry or database. All data elements included in the database or registry must be defined in a data dictionary. In this role, the HIM professional may oversee the completeness and accuracy of the data abstracted for inclusion in the database or registry. This chapter explains the difference between primary and secondary data sources and their uses. It also offers an indepth look at various types of secondary databases, including indexes and registries, and their functions. Finally, the chapter discusses how secondary databases are processed and maintained. record and entered into registries and databases are considered a secondary data source. Data also are categorized as either patient-identifiable data or aggregate data. The health record consists entirely of patient-identifiable data Healthcare Informatics Discussion Assignment Paper.
In other words, every fact recorded in the record relates to a particular patient identified by name. Secondary data also may be patient identifiable. In some instances, data are entered into a database, along with information such as the patient’s name, and maintained in an identifiable form. Registries are an example of patientidentifiable data on groups of patients. More often, however, secondary data are considered aggregate data. Aggregate data include data on groups of people or patients without identifying any particular patient individually. Examples of aggregate data are statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis-related group (DRG). Primary versus Secondary Data Sources and Databases The health record is considered a primary data source because it contains information about a patient that has been documented by the professionals who provided care or services to that patient. Data taken from the primary health Purposes and Users of Secondary Data Sources Secondary data sources consist of facility-specific indexes; registries, either facility or population based; and other healthcare databases. Healthcare organizations maintain those indexes, registries, and databases that are relevant to their specific operations. States as well as the federal government also maintain databases to assess the health and wellness of their populations. Secondary data sources provide information that is not easily available by looking at individual health records. For example, if the HIM director doing a research study wanted to find the health records of 25 patients who had the principal diagnosis of myocardial infarction, he or she would have to look at numerous individual records to locate the number needed. This would be a time-consuming and laborious project. With a diagnosis index, the task would involve simply looking at the list of EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 15_AB103311_ch14.indd 368 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Secondary Records and Healthcare Databases diagnoses in numerical order and selecting those with the appropriate diagnosis code for myocardial infarction for inclusion in the study. Data extracted from health records and entered into disease-oriented databases can, for example, help researchers determine the effectiveness of alternate treatment methods. They also can quickly demonstrate survival rates at different stages of disease. Internal users of secondary data are individuals located within the healthcare facility.
For example, internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities. External users of patient data are individuals and institutions outside the facility. Examples of external users are state data banks and federal agencies. States have laws that mandate cases of patients with diseases such as tuberculosis and AIDS be reported to the state department of health. Moreover, the federal government collects data from the states on vital events such as births and deaths. The secondary data provided to external users is generally aggregate data and not patient-identifiable data. Thus, these data can be used as needed without risking breaches of confidentiality. Check Your Understanding 14.1 Instructions: Answer the following questions on a separate piece of paper. 1. What is the difference between a primary data source and a secondary data source? 2. What is the difference between patient-identifiable data and aggregate data? 3. Why are secondary data sources developed? 4. What are the differences between internal users and external users of secondary data sources? Facility-Specific Indexes The secondary data sources that have been in existence the longest are the indexes that have been developed within facilities to meet their individual needs. An index is simply a report from a database that enables health records to be located by diagnosis, procedure, or physician. Prior to extensive computerization in healthcare, these indexes were kept on cards with handwritten data. They now are usually computerized reports available from data included in databases routinely maintained in the healthcare facility. Most acutecare facilities maintain indexes described in the following subsections. 15_AB103311_ch14.indd 369 Master Population/Patient Index The master population/patient index (MPI), which is sometimes called the master person index, contains patientidentifiable data such as name, address, date of birth, dates of hospitalizations or encounters, name of attending physician, and health record number. Because health records are filed numerically in most facilities, the MPI is an important source of patient health record numbers. These numbers enable the facility to quickly retrieve health information for specific patients. Hospitals with a unit numbering system also depend on the MPI to determine whether a patient has been seen in the facility before and, therefore, has an existing medical record number. Having this information in the MPI avoids issuance of duplicate record numbers. Most of the information in the MPI is entered into the facility database at the time of the admission, preadmission, or registration process. Disease and Operation Indexes In an acute care setting, the disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each patient’s diagnoses are converted from a verbal description to a numerical code, usually using a coding system such as the International Classification of Diseases (ICD). In most cases, patient diagnosis codes are entered into the facility health information system as part of the discharge processing of the patient health record. The index always includes the patient’s health record number as well as the diagnosis codes so that records can be retrieved by diagnosis. Because each patient is listed with the health record number, the disease index is considered patientidentifiable data. The disease index also may include other information such as the attending physician’s name or the date of discharge. In nonacute settings, the disease index might be generated to reflect patients currently receiving services in the facility. The operation index is similar to the disease index except that it is arranged in numerical order by the patient’s procedure code(s) using ICD or Current Procedural Terminology (CPT) codes Healthcare Informatics Discussion Assignment Paper.
The other information listed in the operation index is generally the same as that listed in the disease index except that the surgeon may be listed in addition to, or instead of, the attending physician. In many cases, facilities no longer have an actual listing for the diagnosis and operation indexes. Instead, they query the health information system utilizing the ICD code for the condition or operation needed. Physician Index The physician index is a listing of cases in order by physician name or physician identification number. It also includes the patient’s health record number and may include other information, such as date of discharge. The physician EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 369 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM 370 Chapter 14 Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. index enables users to retrieve information about a particular physician, including the number of cases seen during a particular time period. As with the disease and operation indexes, facilities generally query the health information system (HIS) to obtain physician data. Check Your Understanding 14.2 Instructions: Answer the following questions on a separate piece of paper. 1. How do HIM departments use facility-specific indexes? 2. What is the purpose of the master population/patient index? What types of information does it include? 3. What is the purpose of disease and operation indexes? What types of information do they include? 4. What is the purpose of the physician index? What types of information does it include? Registries Disease registries are collections of secondary data related to patients with a specific diagnosis, condition, or procedure. Registries are different from indexes in that they contain more extensive data. Index reports can usually be produced using data from the facility’s existing databases. Registries often require more extensive data from the patient record. Each registry must define the cases that are to be included in it. This process is called case definition. In a trauma registry, for example, the case definition might be all patients admitted with a diagnosis falling into ICD code numbers 800 through 959, the trauma diagnosis codes. After the cases to be included have been determined through the case definition process described earlier, the next step in data acquisition is usually case finding. Case finding includes the methods used to identify the patients who have been seen and treated in the facility for the particular disease or condition of interest to the registry. After cases have been identified, extensive information is abstracted from the paper-based patient record into the registry database or fed from other databases and entered into the registry database. The sole purpose of some registries is to collect data from the patient health record and to make them available to users. Other registries take further steps to enter additional information in the registry database, such as routine follow-up of patients at specified intervals. Follow-up might include rate and duration of survival and quality-oflife issues over time. Cancer Registries Cancer registries have a long history in healthcare. According to the National Cancer Registrars Association (NCRA), the first hospital registry was founded in 1926, at Yale-New Haven Hospital. It has long been recognized that aggregate clinical information is needed to improve the diagnosis and treatment of cancer. Cancer registries were developed as an organized method to collect these data. The registry may be a facility-based registry (located within a facility such as a hospital or clinic) or a population-based registry (gathering information from more than one facility within a geographic area such as a state or region). The data from facility-based registries are used to provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment. The data collected also may provide comparisons in survival rates and quality of life for patients with different treatments and at different stages of cancer at the time of diagnosis. In population-based registries, emphasis is on identifying trends and changes in the incidence (new cases) of cancer within the area covered by the registry. The Cancer Registries Amendment Act of 1992 provided funding for a national program of cancer registries with population-based registries in each state. According to the law, these registries were mandated to collect data such as Demographic information about each case of cancer Information on the industrial or occupational history of the individuals with the cancers (to the extent such information is available from the same record) ●● Administrative information, including date of diagnosis and source of information ●● Pathological data characterizing the cancer, including site, stage of neoplasm, incidence, and type of treatment ●● ●● Case Definition and Case Finding in the Cancer Registry As defined previously, case definition is the process of deciding what cases should be entered in the registry. In a cancer registry, for example, all cancer cases except certain skin cancers might meet the definition for the cases to be included. Skin cancers such as basal cell carcinomas might be excluded because they do not metastasize and do not require the follow-up necessary for other cancers included in the registry. Data on benign and borderline brain or central nervous system tumors also must be collected by the National Program of Cancer Registries (CDC 2008a). In the facility-based cancer registry, the first step is case finding. One way to find cases is through the discharge process in the HIM department. During the discharge procedure, coders or discharge analysts can easily identify cases of patients with cancer for inclusion in the registry. Another case-finding method is to use the facilityspecific disease indexes or the health information system to identify patients with diagnoses of cancer. Additional methods may include reviews of pathology reports and lists of patients receiving radiation therapy or other cancer EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 15_AB103311_ch14.indd 370 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Secondary Records and Healthcare Databases treatments to determine cases that have not been found by other methods. Population-based registries usually depend on hospitals, physician offices, radiation facilities, ambulatory surgery centers (ASCs), and pathology laboratories to identify and report cases to the central registry. The population-based registry has a responsibility to ensure that all cases of cancer in the target area have been identified and reported to the central registry. Data Collection for the Cancer Registry Data collection methods vary between facility-based registries and population-based registries. When a case is first entered in the registry, an accession number is assigned. This number consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year. The first case in 2012, for example, might be 12-0001. The accession number may be assigned manually or by the automated cancer database used by the organization. An accession registry of all cases can be kept manually or provided as a report by the database software. This listing of patients in accession number order provides a way to monitor that all cases have been entered into the registry. In a facility-based registry, data are initially obtained by reviewing and collecting them from the patient’s health record. In addition to demographic information (such as name, health record number, address), patient data in a cancer registry include Type and site of the cancer Diagnostic methodologies ●● Treatment methodologies ●● Stage at the time of diagnosis ●● ●● The stage provides information on the size and extent of spread of the tumor throughout the body. Historically, several different staging systems have been used. The American Joint Committee on Cancer (AJCC) has worked, through its Collaborative Stage Task Force, with other organizations with staging systems to develop a standardized data set, the Collaborative Stage Data Set, which uses computer algorithms to describe how far a cancer has spread (AJCC 2008). After the initial information is collected at the patient’s first encounter, information in the registry is updated periodically through the follow-up process discussed in the following section. Frequently, the population-based registry only collects information when the patient is diagnosed. Sometimes, however, it receives follow-up information from its reporting entities. These entities usually submit the information to the central registry electronically. Reporting and Follow-up for Cancer Registry Data Formal reporting of cancer registry data is done through an annual report. The annual report includes aggregate data on 15_AB103311_ch14.indd 371 the number of cases in the past year by site and type of cancer. It also may include information on patients by gender, age, and ethnic group. Often a particular site or type of cancer is featured with more in-depth data provided. Other reports are provided as needed. Data from the cancer registry are frequently used in the quality assessment process for a facility as well as in research Healthcare Informatics Discussion Assignment Paper.
Data on survival rates by site of cancer and methods of treatment, for example, would be helpful in researching the most effective treatment for a type of cancer. Another activity of the cancer registry is patient followup. On an annual basis, the registry attempts to obtain information about each patient in the registry, including whether he or she is still alive, status of the cancer, and treatment received during the period. Various methods are used to obtain this information. For a facility-based registry, the facility’s patient health records may be checked for return hospitalizations or visits for treatment. The patient’s physician also may be contacted to determine whether the patient is still living and to obtain information about the cancer. When patient status cannot be determined through these methods, an attempt may be made to contact the patient directly, using information in the registry such as address and telephone number of the patient and other contacts. In addition, contact information from the patient’s health record may be used to request information from the patient’s relatives. Other methods used include reading newspaper obituaries for deaths and using the Internet to locate patients through sites such as the Social Security Death Index and online telephone books. The information obtained through follow-up is important to allow the registry to develop statistics on survival rates for particular cancers and different treatment methodologies. Population-based registries do not always include followup information on the patients in their databases. They may, however, receive the information from the reporting entities such as hospitals, physician offices, and other organizations providing follow-up care. Standards and Approval Agencies for Cancer Registries Several organizations have developed standards or approval processes for cancer programs. (See table 14.1.) The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the Table 14.1. Standard-setting or approval agencies for cancer registries Agency Type of Registry American College of Surgeons (ACS) Facility based North American Association of Central Cancer Registries (NAACCR) Population based Centers for Disease Control and Prevention Population based EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 371 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 372 Chapter 14 requirements of this process is the existence of a cancer registry as part of the program. The ACS standards are published in the Cancer Program Standards (ACS 2008a). When the ACS surveys the cancer program, part of the survey process is a review of cancer registry activities. The North American Association of Central Cancer Registries (NAACCR) has a certification program for state population-based registries. Certification is based on the quality of data collected and reported by the state registry. The NAACCR has developed standards for data quality and format and works with other cancer organizations to align their various standards sets. The Centers for Disease Control and Prevention (CDC) also has national standards regarding completeness, timeliness, and quality of cancer registry data from state registries through the National Program of Cancer Registries (NPCR). The NPCR was developed as a result of the Cancer Registries Amendment Act of 1992. The CDC collects data from the NPCR state registries. Data Collection for Trauma Registries Education and Certification for Cancer Registrars The Abbreviated Injury Scale (AIS) reflects the nature of the injury and the severity (threat to life) by body system. It may be assigned manually by the registrar or generated as part of the database from data entered by the registrar. The Injury Severity Score (ISS) is an overall severity measurement calculated from the AIS scores for the three most severe injuries of the patient (Trauma.org 2008). Traditionally, cancer registrars have been trained through onthe-job training and professional workshops and seminars. The NCRA has worked with colleges to develop formal educational programs for cancer registrars either through a certificate or an associate’s degree program. A cancer registrar may become certified as a certified cancer registrar (CTR) by passing an examination provided by the National Board for Certification of Registrars (NBCR). Eligibility requirements for the certification examination include a combination of experience and education (NCRA 2008). Trauma Registries Trauma registries maintain databases on patients with severe traumatic injuries. A traumatic injury is a wound or another injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall. Examples of such injuries would include fractures, burns, and lacerations. Information collected by the trauma registry may be used for performance improvement and research in the area of trauma care. Trauma registries are usually facility based but may, in some cases, include data for a region or state. Case Definition and Case Finding for Trauma Registries The case definition for the trauma registry varies from registry to registry. To find cases with trauma diagnoses, the trauma registrar may query the HIS system looking for cases with codes in the trauma section of ICD. In addition, the registrar may look at deaths in services with frequent trauma diagnoses such as trauma, neurosurgery, orthopedics, and plastic surgery to find additional cases. After the cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database. The data elements collected in the abstracting process vary from registry to registry but usually include Demographic information on the patient Information on the injury ●● Care the patient received before hospitalization (such as care at another transferring hospital or care from an emergency medical technician who provided care at the scene of the accident or in transport from the accident site to the hospital) ●● Status of the patient at the time of admission ●● Patient’s course in the hospital ●● ICD diagnosis and procedure codes ●● Abbreviated Injury Scale (AIS) ●● Injury Severity Score (ISS) ●● ●● Reporting and Follow-up for Trauma Registries Reporting varies among trauma registries. An annual report is often developed to show the activity of the trauma registry. Other reports may be generated as part of the performance improvement process, such as self-extubation (patients removing their own tubes) and delays in abdominal surgery or patient complications. Some hospitals report data to the National Trauma Data Bank, a large database of aggregate data on trauma cases (ACS 2008b). An example of the use of such population data is the number of head injuries from motorcycle accidents in a state to encourage passage of a helmet law. Trauma registries may or may not do follow-up of the patients entered in the registry. When follow-up is done, emphasis is frequently on the patient’s quality of life after a period of time. Unlike cancer, where physician follow-up is crucial to detect recurrence, many traumatic injuries do not require continued patient care over time. Thus, follow-up is often not given the emphasis it receives in cancer registries. Standards and Agencies for Approval of Trauma Registries The American College of Surgeons certifies levels I, II, III, and IV trauma centers. As part of its certification requirements, the ACS states that the level I trauma center, the type of center receiving the most serious cases and providing the highest level of trauma service, must have a trauma registry (ACS 2008b). EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 15_AB103311_ch14.indd 372 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Secondary Records and Healthcare Databases Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Education and Certification of Trauma Registrars Trauma registrars may be registered health information technicians (RHITs), registered health information administrators (RHIAs), registered nurses (RNs), licensed practical nurses (LPNs), emergency medical technicians (EMTs), or other health professionals. Training for trauma registrars is accomplished through workshops and on-the-job training Healthcare Informatics Discussion Assignment Paper.
The American Trauma Society (ATS), for example, provides core and advanced workshops for trauma registrars. It also provides a certification examination for trauma registrars through its Registrar Certification Board. Certified trauma registrars have earned the certified specialist in trauma registry (CSTR) credential. Birth Defects Registries Birth defects registries collect information on newborns with birth defects. Often population based, these registries serve a variety of purposes. For example, they provide information on the incidence of birth defects to study causes and prevention of birth defects, to monitor trends in birth defects to improve medical care for children with birth defects, and to target interventions for preventable birth defects such as folic acid to prevent neural tube defects. In some cases, registries have been developed after specific events have put a spotlight on birth defects. After the initial Persian Gulf War, for example, some feared an increased incidence of birth defects among the children of Gulf War veterans. The Department of Defense subsequently started a birth defects registry to collect data on the children of these veterans to determine whether any pattern could be detected. Case Definition and Case Finding for Birth Defects Registries Birth defects registries use a variety of criteria to determine which cases to include in the registry. Some registries limit cases to those birth defects found within the first year of life. Others include those children with a major defect that occurred in the first year of life and was discovered within the first five years of life. Still other registries include only children who were liveborn or stillborn babies with discernible birth defects. Cases may be detected in a variety of ways, including review of disease indexes, labor and delivery logs, pathology and autopsy reports, ultrasound reports, and cytogenetic reports. In addition to information from hospitals and physicians, cases may be identified from rehabilitation centers and children’s hospitals and from vital records such as birth, death, and fetal death certificates. Data Collection for Birth Defects Registries A variety of information is abstracted for the birth defects registry, including 15_AB103311_ch14.indd 373 Demographics Codes for diagnoses ●● Birth weight ●● Status at birth, including liveborn, stillborn, aborted ●● Autopsy ●● Cytogenetics results ●● Whether the infant was a single or multiple birth ●● Mother’s use of alcohol, tobacco, or illicit drugs ●● Father’s use of drugs and alcohol ●● Family history of birth defects ●● ●● Diabetes Registries Diabetes registries collect data about patients with diabetes for the purpose of assistance in managing care as well as for research. Patients whose diabetes is not kept under good control frequently have numerous complications. The diabetes registry can keep up with whether the patient has been seen by a physician in an effort to prevent complications. Case Definition and Case Finding for Diabetes Registries There are two types of diabetes mellitus: insulin-dependent diabetes (type I) and non-insulin-dependent diabetes (type II). Registries sometimes limit their cases by type of diabetes. In some instances, there may be further definition by age. Some diabetes registries, for example, only include children with diabetes. Case finding includes the review of health records of patients with diabetes. Other case-finding methods include the reviews of the following types of information: ICD diagnostic codes Billing data ●● Medication lists ●● Physician identification ●● Health plans ●● ●● Although facility-based registries for cancer and trauma are usually hospital based, facility-based diabetes registries are often maintained by physician offices and clinics because they are the main location for diabetes care. Thus, the data about the patient to be entered into the registry are available at these sites rather than at the hospital Healthcare Informatics Discussion Assignment Paper.
Patient health records of diabetes patients in the physician practice may be identified through ICD code numbers for diabetes, billing data for diabetes-related services, medication lists for patients on diabetic medications, or identification of patients as the physician sees them. Health plans also are interested in optimal care for their enrollees because diabetes can have serious complications when not managed correctly. They may provide information to the office or clinic on diabetic enrollees in the health plan. EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 373 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM 374 Chapter 14 Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Data Collection for Diabetes Registries In addition to demographic information about the cases, other data collected may include laboratory values such as HbA1c. This test is used to determine the patient’s blood glucose level for a period of approximately 60 days prior to the time of the test. Moreover, facility registries may track patient visits to follow up with patients who have not been seen in the past year. Reporting and Follow-up for Diabetes Registries A variety of reports may be developed from the diabetes registry. For facility-based registries, one report may keep up with laboratory monitoring of the patient’s diabetes to allow intensive intervention with patients whose diabetes is not well controlled. Another report might be of patients who have not been tested within a year or who have not had a primary care provider visit within a year. Population-based diabetes registries might provide reporting on the incidence of diabetes for the geographic area covered by the registry. Registry data also may be used to investigate risk factors for diabetes. Follow-up is aimed primarily at ensuring that the diabetic is seen by the physician at appropriate intervals to prevent complications. Implant Registries An implant is a material or substance inserted in the body, such as breast implants, heart valves, and pacemakers. Implant registries have been developed for the purpose of tracking the performance of implants, including complications, deaths, and defects resulting from implants, as well as longevity. In the recent past, the safety of implants has been questioned in a number of highly publicized cases. In some cases, implant registries have been developed in response to such events. For example, there have been questions about the safety of silicone breast implants and temporomandibular joint implants. When such cases arise, it has often been difficult to ensure that all patients with the implant have been notified of safety concerns. A number of federal laws have been enacted to regulate medical devices, including implants. These devices were first covered under Section 15 of the Food, Drug, and Cosmetic Act. The Safe Medical Devices Act of 1990 was passed and then amended through the Medical Device Amendments of 1992. These acts required facilities to report deaths and severe complications thought to be due to a device to the manufacturer and the Food and Drug Administration (FDA) through its MedWatch reporting system. Implant registries can help in complying with the legal requirement for reporting for the sample of facilities required to report. Case Definition and Case Finding for Implant Registries Implant registries sometimes include all types of implants but often are restricted to a specific type of implant such as cochlear, saline breast, or temporomandibular joint. Data Collection for Implant Registries Demographic data on patients receiving implants are included in the registry. The FDA requires that all reportable events involving medical devices include information on the following (FDA 2008): User facility report number Name and address of the device manufacturer ●● Device brand name and common name ●● Product model, catalog, and serial and lot number ●● Brief description of the event reported to the manufacturer or the FDA ●● ●● Thus, these data items also should be included in the implant registry to facilitate reporting. Reporting and Follow-up for Implant Registries Data from the implant registry may be used to report to the FDA and the manufacturer when devices cause death or serious illness or injury. Follow-up is important to track the performance of the implant. When patients are tracked through the registry, they can be easily notified of product failures, recalls, or upgrades. Transplant Registries Transplant registries may have varied purposes. Some organ transplant registries maintain databases of patients who need organs. When an organ becomes available, an equitable way then may be used to allocate the organ to the patient with the highest priority. In other cases, the purpose of the registry is to provide a database of potential donors for transplants using live donors, such as bone marrow transplants. Posttransplant information also is kept on organ recipients and donors. Because transplant registries are used to match donor organs with recipients, they are often national or even international in scope Healthcare Informatics Discussion Assignment Paper.
Examples of national registries include the UNet of the United Network for Organ Sharing (UNOS) and the registry of the National Marrow Donor Program (NMDP). Data collected in the transplant registry also may be used for research, policy analysis, and quality control projects. Case Definition and Case Finding for Transplant Registries Physicians identify patients needing transplants. Information about the patient is provided to the registry. When an organ becomes available, information about it is matched with potential donors. For donor registries, donors are solicited EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 15_AB103311_ch14.indd 374 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Secondary Records and Healthcare Databases through community information efforts similar to those carried out by blood banks to encourage blood donations. Data Collection for Transplant Registries Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. The type of information collected varies according to the type of registry. Pretransplant data about the recipient include Demographics Patient’s diagnosis ●● Patient’s status codes regarding medical urgency ●● Patient’s functional status ●● Whether the patient is on life support ●● Previous transplantations ●● Histocompatibility—“a state of immunologic similarity (or identity) that permits successful homograft transplantation” (Stedman’s Online Dictionary) ●● ●● Information on donors varies according to whether the donor is living. For organs harvested from patients who have died, information is collected on Cause and circumstances of the death Organ procurement and consent process ●● Medications the donor was taking ●● Other donor history ●● ●● For a living donor, information includes Relationship of the donor to the recipient (if any) Clinical information ●● Information on organ recovery ●● Histocompatibility ●● ●● Reporting and Follow-up for Transplant Registries Reporting includes information on donors and recipients as well as survival rates, length of time on the waiting list for an organ, and death rates. Follow-up information is collected for recipients as well as living donors. For living donors, the information collected might include complications of the procedure and length of stay (LOS) in the hospital. Follow-up information about recipients includes information on status at the time of follow-up (for example, living, dead, lost to follow-up), functional status, graft status, and treatment, such as immunosuppressive drugs. Follow-up is carried out at intervals throughout the first year after the transplant and then annually after that. Immunization Registries Children are supposed to receive a large number of immunizations during the first six years of life. These immunizations are so important that the federal government has set several objectives related to immunizations in Healthy People 2010, a set of health goals for the nation (HHS 2000). These include increasing the proportion of children and adolescents who are fully immunized (Objective 14-24) and increasing the proportion of children in population-based immunization registries (Objective 14-26). 15_AB103311_ch14.indd 375 Immunization registries usually have the purpose of increasing the number of infants and children who receive proper immunizations at the proper intervals Healthcare Informatics Discussion Assignment Paper.
To accomplish this goal, they collect information within a particular geographic area about children and their immunization status. They also help by maintaining a central source of information for a particular child’s immunization history, even when the child has received immunizations from a variety of providers. This central location for immunization data also relieves parents of the responsibility of maintaining immunization records for their own children. Case Definition and Case Finding for Immunization Registries All children in the population area served by the registry should be included in the registry. Some registries limit their inclusion of patients to those seen at public clinics, excluding those seen exclusively by private practitioners. Although children are usually targeted in immunization registries, some registries do include information on adults for influenza and pneumonia vaccines. Children are often entered in the registry at birth. Registry personnel may review birth and death certificates and adoption records to determine what children to include and what children to exclude because they died after birth. In some cases, children are entered electronically through a connection with an electronic birth record system. Accuracy and completeness of the data in the registry are dependent on the thoroughness of the submitters in reporting immunizations. Data Collection for Immunization Registries The National Immunization Program at the CDC has worked with the National Vaccine Advisory Committee (NVAC) to develop a set of core immunization data elements to be included in all immunization registries. The data elements are divided into required and optional. The required data elements include (CDC 2008b) Patient’s name (first, middle, and last) Patient’s birth date ●● Patient’s sex ●● Patient’s birth state and country ●● Mother’s name (first, middle, last, and maiden) ●● Vaccine type ●● Vaccine manufacturer ●● Vaccination date ●● Vaccine lot number ●● ●● Other optional items may be included, as needed, by the individual registry. Reporting and Follow-up for Immunization Registries Because the purpose of the immunization registry is to increase the number of children who receive immunizations EBSCO : eBook Business Collection Trial – printed on 4/1/2018 11:37 AM via LOUISIANA STATE UNIV AT SHREVEPORT AN: 667492 ; LaTour, Kathleen M., American Health Information Management Association, Eichenwald, Shirley, Oachs, Pamela K..; 375 Health Information Management : Concepts, Principles, and Practice Account: s3563253.main.ehost 12/21/12 7:23 PM Copyright @ 2013. AHIMA Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 376 Chapter 14 in a timely manner, reporting should emphasize immunization rates, especially changes in rates in target areas. Immunization registries also can provide automatic reporting of children’s immunization to schools to check the immunization status of their students. Follow-up is directed toward reminding parents that it is time for immunizations as well as seeing whether the parents do not bring the child in for the immunization after a reminder. Reminders may include a letter or postcard or telephone calls. Autodialing systems may be used to call parents and deliver a prerecorded reminder. Moreover, registries must decide how frequently to follow up with parents who do not bring their children for immunization. Maintaining up-to-date addresses and telephone numbers is an important factor in providing follow-up. Healthcare Informatics Discussion Assignment Paper Purchase to get full answer
Place an order in 3 easy steps. Takes less than 5 mins.