Indexes are a guide that is used as a pointer, or indicator to locate information on disease, physicians, and procedures/operations.Registries are data listed in chronological order, registries hold information on cancer, and trauma’s.Databases is a collection of organized data saved in a binary-type file.
What are indexes or registries?
Indexes or registries provide baseline information in a retrievable format and are fundamental components in managing a facility’s health information.At a minimum, every long term care facility should maintain a master patient index (MPI) and admission and discharge register. The disease index is optionalunless required by state law.
What are indices registries and databases in nursing?
In summary, indices, registries, and databases are all important for quality management, research, and quality of care for each facility. To recap the different indices, registries and databases there are:Master Patient Index, Disease indexes, Procedure indexes, and Physician indexes.
What is the difference between indexes and databases?
Indexes are a guide that is used as a pointer, or indicator to locate information on disease, physicians, and procedures/operations.Registries are data listed in chronological order, registries hold information on cancer, and trauma’s.Databases is a collection of organized data saved in a binary-type file.
What are the data required for a patient index?
Essentially, the datarequired in these indexes include the physician's name and code; the health record number; the diagnoses, operation (s), and disposition of patients treated; dates of the patient's admission and discharge; and the patient's gender and age.
What are indexes registers and healthcare databases quizlet?
Data collected from a primary data source such as the patient's health record. Registries, indexes, or databases that contains data that was collected from the patient's health record. A database composed of data fields used to store collected data on trauma patients treated by a hospital.
What are databases in healthcare?
What is it? Healthcare databases are systems into which healthcare providers routinely enter clinical and laboratory data. One of the most commonly used forms of healthcare databases are electronic health records (EHRs).
What is indexing in health care?
Medical record indexing is a popular practise that entails streamlined organizing, cataloguing and storing of patients` medical information. It has evolved as an integral part of medical operations. In the United States of America, it is a mandate to maintain patients medical records for a minimum of seven years.
What three indexes are used in healthcare?
list the kinds of indexes used in healthcare:Master patient index.Disease index.Procedure index.Physician index.
What is a registry in healthcare?
A clinical registry is a computer database that collects information about your health and the care you receive as a patient. The data in the registry comes from the information your healthcare provider collects while providing your care and is added to information on other patients who are similar to you.
What are some examples of healthcare data sets?
10 Great Healthcare Data SetsBig Cities Health Inventory Data. ... Healthcare Cost and Utilization Project (HCUP) ... data.gov. ... Kent Ridge Bio-medical Dataset. ... HealthData.gov. ... MHEALTH Dataset Data Set. ... Surveillance, Epidemiology & End Results (SEER)-Medicare Health Outcomes Survey (MHOS) ... The Human Mortality Database (HMD)More items...•
What does it mean to index medical records?
What is medical record indexing? Medical record indexing is the process of organizing medical records and information into an accessible user friendly system.
What are the four major indices in healthcare organizations?
These measures are currently organized into four modules: the Prevention Quality Indicators (PQIs),1 the Inpatient Quality Indicators (IQIs),2 the Patient Safety Indicators (PSIs),3 and the Pediatric Quality Indicators (PDIs).
Why is it important to index medical data?
Medical records indexing is an important function since it involves organizing and storing information such as the patient's demographic and treatment information together in one place for easy retrieval later.
What are the types of index?
Expression-based indexes efficiently evaluate queries with the indexed expression.Unique and non-unique indexes. ... Clustered and non-clustered indexes. ... Partitioned and nonpartitioned indexes. ... Bidirectional indexes. ... Expression-based indexes.
What is disease index?
The disease index comprised of those patients who have specific diseases. In other words the index is made up of all the diseases that have been coded by the facilityDisease indices are used for finding patient records with specific disease’s for quality improvement, research studies, and for monitoring quality of care.You access the disease indices by compiling or aggregating the data into a report, which is then viewed either on the workstation or printed.
What is a physician index?
Just like a disease or operation index, a physician index is a guide to identifying medical cases associated with a specific physician. Essentially, the datarequired in these indexes include the physician's name and code; the health record number; the diagnoses, operation (s), and disposition of patients treated; dates of the patient's admission and discharge; and the patient's gender and age. Often, depending on the application of the information, other demographic items could be included.
What is NEDSS data?
NEDSS (National Electronic Disease Surveillance System) is an Internet-based infrastructure for public health surveillance data exchange that uses specific PHIN (Public Health Information Network) and NEDSS Data Standards. NEDSS also relies heavily on industry standards (including: standard vocabulary code sets such as LOINC, SNOMED, and HL7), policy-level agreements on data access, and the protection of confidentiality. NEDSS represents an ongoing close collaboration between the CDC and its public health partners. NEDSS is not a single, monolithic application, but a system of interoperable subsystems, components and systems modules that include software applications developed and implemented by the CDC; those developed and implemented by State and Local health departments and those created by commercial services and vendors.
What is a HIPDB?
The Healthcare Integrity and Protection Data Bank (HIPDB) is a federal data banks that have been created to serve as repositories of information about health care providers in the United States. Federal law requires that adverse actions taken against a health care professional's license be reported to these data banks. Information about nursing discipline actions is reported to the HIPDB by the board taking action. All Information included in the NPDB and HIPDB is NOT available to the general public. Access to information in the NPDB and HIPDB is limited to those entities specified by law as listed below.
What is procedure index?
The only difference is what the HIM professional is looking for, so they will put in certain criteria to find the information they want.The procedure index is the type of procedures done and coded by the facility, it is used to find patient health records who had certain procedures, it is also used for quality improvement, research studies and monitoring the quality of care. Access is facility specific, so it is only accessible by entering the required criteria into the system, then you are able to view or printout a hardcopy to look at.
What is the master patient index?
The MPI is an index that lists all the patients that have been seen in a facility, it contains patient identifiable data which includes name, address, date of birth, date of hospitalizations or encounters, attending physicians name, and the number of the health record. The MPI is used to quickly find patients for any given query the HIM office person enters. The MPI is facility specific and can only be accessed by specific query information into the system, such as name, SS#, etc. this will bring up the information if the patient has been seen before by the facility. If nothing comes up then this patient has probably never been seen by that facility.
Why are indices important?
In summary, indices, registries, and databases are all important for quality management, research, and quality of care for each facility. To recap the different indices, registries and databases there are:Master Patient Index, Disease indexes, Procedure indexes, and Physician indexes. Each of these are similar to the others as far as content, use and access. Each of these are facility specific, so there is no set rule to follow.Registries include, Admission, Discharge, Birth, Death, Cancer and trauma, there are others besides these that are listed. Each of these registries are similar in some extent to indexes, although these have rules and standards that must be followed since like the Cancer registry is not facility specific so it has a set format, and entry requirements.The databases are numerous and each one is vital in it’s own way. The use of databases helps to have all data that a facility will need for quality improvements, quality of care checks, and for research.The following are databases; Healthcare Cost and utilization project, health effectiveness data and information, national ambulatory care survey, national hospital ambulatory medical care survey, national nursing home survey, national home and hospice care survey, national electronic disease surveillance system, clinical trials database, national practitioners databank, clinical trials database, national practitioners databank, healthcare integrity and protection databank, Medicare provider and analysis review.
What information is reported in the physician index?
Other information routinely reported in the physician index includes the surgeon's name, patient name, patient medical record number, admission date, discharge date, diagnosis code. A list of physicians and the patients each physician has treated within the facility for a specific period of time (e.g.
What is a medical record number?
The medical record number is a unique patient identifier.
What is a programmed rule in MPI?
Programmed rules used by a computer program to identify potential duplicate record errors in an MPI by comparing certain data elements such as the patient name, date of birth, social security number, gender, etc. to locate exact and partial matched data among records.
What is MPI matching?
An advanced programmed matching technique used by a computer program to identify potential errors in an MPI . This technique matches specific data among records and assigns a weight based on the likelihood that a data element matched indicates a duplicate record.
What is the second record in MPI?
The creation of a second record in an MPI on a single patient which occurs when a patient has been assigned multiple unique patient identifiers, results in a patient having multiple health records within a single healthcare organization.
What is primary data?
Primary data. Information that is collected during patient care; in essence, the health record. Primary data source. The originating source of data where data is collected and documented by the author of data at the point of service.
What is the purpose of collecting cancer data?
The data provides researchers and public health officials with information regarding cancer prevention, treatments, and screenings.
What is registry in healthcare?
A Registry is. a system for the collection, storage, retrieval, and analysis of data. Information is pulled from the health record thus becoming a secondary source of information.
What is CIHI data?
collection of data on accidents. The Canadian Institute of Health Information (CIHI) maintains an Ontario and a National Registry
What is the purpose of health information department?
an automated or manual process performed by health information department staff to collect patient information to determine prospective payment system status, generate indexes and to report data to quality improvement organizations and state/federal/provincial agencies.
What is data timeliness?
Data timeliness - (or data currency)-date must be collected and available to the user within a reasonable amount of time and up to date.
What is registry in computer science?
A Registry is a system for the collection, storage, retrieval, and analysis of data.
What is de-identified data?
De-identified data is sourced from a variety of sources or records and compiled into specific categories that help facilities to compare and analyze
What is the purpose of the health record?
a system for the collection, storage, retrieval, and analysis of data. Information is pulled from the health record thus becoming a secondary source of information
What is a master patient index?
Indexes or registries provide baseline information in a retrievable format and are fundamental components in managing a facility’s health information.At a minimum, every long term care facility should maintain a master patient index (MPI) and admission and discharge register. The disease index is optionalunless required by state law.
How long do you keep a disease index?
Unless otherwise specified by state law, the recommended retention period for a disease index is 10 years.
Why is MPI information computerized?
Computerized MPI information has many advantages for an organization including ease in access and retrieval. Because of current limitations in software programs available in the long term care industry, consider the following before moving to a fully computerized MPI:
Why is MPI important?
An index can be maintained manually or as part of a computerized system. Because the information in the MPI is important for tracking resident stays in an organization, the MPI should be retained on a permanent basis. Information on the MPI should be updated with changes throughout the residents’ stay.
What is census register?
An admission and discharge register (or census register) lists chronologically all admissions and discharges by date. This type of register can be maintained either manually or on a computer system. Some states require a specific format such as a bound book which continues to be the most common format used for this type of register.
How to maintain MPI?
On admission the face sheet is printed, kept updated throughout the residents’ stay and on discharge, the discharge date and disposition are documented. The face sheets are maintained alphabetically and retained on a permanent basis.
What is the MPI in a long term care facility?
The content or format of the MPI may vary from health care facility. At a minimum, the MPI in a long term care facility should contain the following data elements : Resident name (legal name including surname, given name, middle name or initial, name suffixes (Junior, IV), and prefixes (Father, Doctor).
What is a death index?
Death and birth records—Death indexes are national databases tracking population death data (e.g., the NDI7and the Death Master File [DMF] of the Social Security Administration [SSA]8) . Data include patient identifiers, date of death, and attributed causes of death. These indexes are populated through a variety of sources. For example, the DMF includes death information on individuals who had an SSN and whose death was reported to the SSA. Reports may come in to the SSA by different paths, including from survivors or family members requesting benefits or from funeral homes. Because of the importance of tracking Social Security benefits, all States, nursing homes, and mortuaries are required to report all deaths to the SSA. Prior to 2011, the DMF contained virtually 100-percent complete mortality ascertainment for those eligible for SSA benefits. As of November 2011, however, the DMF no longer includes protected State death records. In practical terms, this means that approximately 4.2 million records were removed from the historical public DMF (which contained 89 million records), and some 1 million fewer records will be added to the DMF each year.9The NDI can be used to provide both fact of death and cause of death, as recorded on the death certificate. Cause-of-death data in the NDI are relatively reliable (93–96 percent) compared with death certificates.10, 11Time delays in death reporting should be considered when using these sources, and vital status should not be assumed to be “alive” by the absence of information at a recent point in time. These indexes are valuable sources of data for death tracking. Of course, mortality data can be accessed directly through queries of State vital statistics offices and health departments when targeting information on a specific patient or within a State. Likewise, birth certificates are available through State departments and may be useful in registries of children or births.
What is an institutional database?
Institutional or organizational databases— Institutional or organizational databases may be evaluated as potential sources of a wide variety of data. System-wide institutional or hospital databases are central data repositories, or data warehouses, that are highly variable from institution to institution. They may include a portion of everything from admission, discharge, and transfer information to data reflecting diagnoses and treatment, pharmacy prescriptions, and specific laboratory tests. Laboratory test data might be chemistry or histology laboratory data, including patient identifiers with associated dates of specimen collection and measurement, results, and standard “normal” or reference ranges. Catheterization laboratory data for cardiac registries may be accessible and may include details on the coronary anatomy and percutaneous coronary intervention. Other organizational examples are computerized order entry systems, pharmacies, blood banks, and radiology departments.
How important is patient identifiers?
The importance of patient identifiers for linking to secondary data sources cannot be overstated. Multiple patient identifiers should be used, and primary data for these identifiers should not be entered into the registry unless the identifying information is complete and clear. While an SSN is very useful, high-quality probabilistic linkages can be made to secondary data sources using various combinations of such information as name (last, middle initial, and first), date of birth, and gender. For example, the NDI will make possible matches when at least one of seven matching conditions is met (e.g., one matching condition is “exact month and day of birth, first name, and last name”). However, the degree of success in such probabilistic and deterministic matching generally is enhanced by having many identifiers to facilitate matching. As noted earlier, the various types of data (e.g., personal history, adverse events, hospitalization, and drug use) have to be linked through a common identifier. A discussion of both statistical and privacy issues in linkage is provided in Chapter 16, and a discussion of managing patient identity across systems is provided in Chapter 17.
Why are electronic health records important?
EHRs have an advantage over paper medical records because the data in some EHRs can be readily searched and integrated with other information (e.g., laboratory data). The ease with which this is accomplished depends on whether the information is in a relational databaseaor exists as scanned documents. An additional challenge relates to terminology and relationships. For example, including the term “fit” in a search for patients with epilepsy can yield a record for someone who was noted as “fit,” meaning “healthy.” Relationships can also be difficult to identify through searches (e.g., “Patient had breast cancer” vs. “Patient's mother had breast cancer”). The quality of the information has the same limitations as described in the paragraph above. Both the availability and standardization of EHR data have grown significantly in recent years, and this trend is expected to continue. As of 2009, some data suppliers cited individual data sets exceeding 10 million lives.1More recently, data suppliers are reporting 20 million2to 35 million3patients in their data sets. Further, it is anticipated that more significant standardization of EHR data will result from the “EHR certification” requirements being developed in phases under the American Recovery and Reinvestment Act of 2009 (ARRA). Such standardization should increase not only the availability and utility of EHR records, but also the ability to aggregate them into larger data sources.
What is medical chart abstraction?
Medical chart abstraction—Medical charts primarily contain information collected as a part of routine medical care. These data reflect the practice of medicine or health care in general and at a specific level (e.g., geographical, by specialty care provider). Charts also reflect uncontrolled patient behavior (e.g., noncompliance). Collection of standard medical practice data is useful in looking at treatments and outcomes in the real world, including all of the confounders that affect the measurement of effectiveness (as distinguished from efficacy) and safety outside of the controlled conditions of a clinical trial. Chart documentation is often much poorer than one might expect, and there may be more than one patient-specific medical record (e.g., hospital and clinical records). A pilot collection is recommended for this labor-intensive method of data collection to explore the availability and reproducibility of the data of interest. It is important to recognize that physicians and other clinicians do not generally use standardized data definitions in entering information into medical charts, meaning that one clinician's documented diagnosis of “chronic sinusitis” or “osteoarthritis” or description of “pedal edema” may differ from that of another clinician.
What are Medicare claims files?
Medicare and Medicaid claims files are two examples of commonly used administrative databases. The Medicare program covers over 43 million people in the United States, including almost everyone over the age of 65, people under the age of 65 who qualify for Social Security Disability, and people with end-stage renal disease.4The Medicaid program covers low-income children and their mothers; pregnant women; and blind, aged, or disabled people. As of 2007, approximately 40 million people were covered by Medicaid.5Medicare and Medicaid claims files, maintained by the Centers for Medicare & Medicaid Services (CMS), can be obtained for inpatient, outpatient, physician, skilled nursing facility, durable medical equipment, and hospital services. As of 2006, Medicare claim files for prescription drugs can also be obtained. The claims files generally contain person-specific data on providers, beneficiaries, and recipients, including individual identifiers that would permit the identity of a beneficiary or physician to be deduced. Data with personal identifiers are clearly subject to privacy rules and regulations. As such, the information is confidential and to be used only for reasons compatible with the purpose(s) for which the data are collected. The Research Data Assistance Center (ResDAC), a CMS contractor at the University of Minnesota, provides assistance to academic, government, and nonprofit researchers interested in using Medicare and/or Medicaid data for their research.6
What is the purpose of a medical database?
Administrative databases—Private and public medical insurers collect a wealth of information in the process of tracking health care, evaluating coverage, and managing billing and payment. Information in the databases includes patient-specific information (e.g., insurance coverage and copays; identifiers such as name, demographics, SSN or plan number, and date of birth) and health care provider descriptive data (e.g., identifiers, specialty characteristics, locations). Typically, private insurance companies organize health care data by physician care (e.g., physician office visits) and hospital care (e.g., emergency room visits, hospital stays). Data include procedures and associated dates, as well as costs charged by the provider and paid by the insurers. Amounts paid by insurers are often considered proprietary and unavailable. Standard coding conventions are used in the reporting of diagnoses, procedures, and other information. Coding conventions include the Current Procedure Terminology (CPT) for physician services and International Classification of Diseases (ICD) for diagnoses and hospital inpatient procedures. The databases serve the primary function of managing and implementing insurance coverage, processing, and payment. (See Case Example 12.)