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HIT 218 CH14

What is primary data? The information contained in the actual patient record.
What is secondary data? Information that is generated from the record
What is a registry? It's a systematic collection of data specific to a type of disease.
Surveillance mechanisms The collection collation, analysis and dissemination of data
Incidence measures Occurrence
what is a case? a person with a given disease or condition that will be included in the registry
CDC centers for disease control and prevention
epidemiologic case definitions diseases that must be reported to a public health agency
clinical case definition a list of signs and symptoms that establish a clinical diagnosis
case finding the method by which all the eligible cases to be included in the registry are identified, accessioned into the registry and abstracted
abstracting a set of predetermined data obtained formt he patient record and related sources
cancer registries the most common type of registry
ACS American college of surgeons
SEER Program surveillance, epidemiology and end results program
NCI national cancer institute
Primary goal of hospital based cancer registries to improve patient care
CoC comission on cancer
case eligibility for most cancer registries is defined by? all the organizations patients diagnosed (clinically or histologically) or treated for active diseases on or after the reference date or beginning of the registry are elibible for inclusion
accesioned into the registry means when patientes are determined eligible and added to the registry
3 types of population based cancer registries incidence only, cancer control and research
incidence only registries operated by a government health agency and designed to determine cancer rates and trends in a defined population
cancer control population bassed registries serve a broader function often combining incidence, patient care and end results reporting with various other research and cancer control activities such as cancer screening and smoking cessation programs
etiology the study of the causes of disease
cancer abstract must permit recording of all relevant data in a logical and uniform manner
WHO world health organization
NCRA national cancer registrars association inc
topography site
morphology cell structure and form
grading variotion from normal tissue
differentiation another term for varioation from normal tissue
AJCC american joint committee on cancer
NAACCR North American Association of Central Cancer Registries, INC
NCDB National Cancer Data Base
birth defects the leading cause of infant mortality in the US
genetic diseases account for about one half of pediatric hospital admissions
active case ascertainment surveillance systems that identify cases in all hospitals clinics or other medical facilities through systematic review of patient records, surgery records disease indexes pathology reports vital records and hospital logs
passive case ascertainment surveillance systems that rely on reports submitted to the registry by hospitals, clinics orother facilities, supplemented with data from vital statistics
MACDP metropolitan atlanta congenital defects program
major birth defects those that affect survival require substantial medical care or result in marked physiological or psychological impairment
types of diabetes that are monitored IDDM, NIDDM, Gestational and maternal
implant registry used to locate a person in case of a recall of the implant
immunization registries collect vaccination information about children within a geographic area
UNOS united network for organ sharing
OPTN organ procurement and transplantataion network
ACSCOT ACS committee on trauma
NTDB national trauma data bank
AIS abbreviated injury scale
APR-DRGs All Patient Refined DRGs
DCG diagnostic cost groups
ACGs adjusted clinical groups
CCS clinical classification software
health services research an applied field that encompasses many disciplines, generation of knowledge through scientific inquiry about how resources, organization, financing and policies relate to the provision of health services
2 main areas of research 1st focuses on the organizational level and the 2nd on the policy level
comorbidity a condition that is in addition to a primary condition and that affects the course or treatment of a condition
APACHE acute physiology, age and chronic health evaluation
CODES crash outcomes data evaluation system
possible bioterrorism is monitored by surveillance systems using coded data
pay for performance main goal is to improve patient safety and to increase the methods for management of chronic disease
outcome the results of a process
NCQA national committee for quality assurance
HEDIS health plan employer data and information set
HIS health care information systems
HIS operational systems that work with the transactional data on a single patient at a time
MHCA Mental Health Council of America
CPT current procedural terminology
example of a universal coding scheme the internation classification of clinical services originally developed by Stan Mendenhall at the commission on professional and hospital activities in an attempt to standardize descriptions of treatmetnes and to provide more clinical data within codes
Desirable outcome systems it is desirable that data collection systems be available wherever care is rendered whethere in an office at a bedside in a home or at a remote location and that the data be entered by thte person first acquiring it
need for a master identifier is just as critical for caregiver records as it is for patients
data sampling - identifying the characteristics and volume of records to be included in a given analysis
grouping continuing analysis requires that data be segmented into meaningful subsets
tabular and graphical reporting reporting rfunctionality runs that gamut from rigid standardized reports in flat tabular formats to flexible ad hoc reports that all the user to drill through increasing layers of detail, shift, resort and present a variety of graphical formats
modeling changes in treatment patterns, resource, mix, staffing and so forth
indicator reporting functions performance measurement requiring the collection and dissemination of indicators both internally and to third parties
benchmarking / comparative reporting capabilities should be able to operate over both detailed internal data and external comparative data
DCE distributed computing environment
clinical decision support a system that brings knowledge to caregivers to assist them in making decisions about patient care
data dictionary critical to the EHR as the English dictionary is to other forms of communication
metadata data about data
data element atomic level of information; a single question that demands a singular defined response
field a physical term that refers to the place ina computer system in which a data element might reside
entities "subject"; represents a higher level than the data element, a subject of information that may be a thing a concept or a process
table the physical representation of the entity
record a row within the table, containing data elements within fields that will provide sufficient data to identify a unique instance of the entity
attributes a data element that describes the entity (column)
domain the type of value that is allowable for a specific element
value/coding represents a more specified way that values may be returned to the data element question
logical data model the structure of the relationship of data elelments and entities within an information system
data dictionary should include all the elements that are required for a person or institution to make key business decisions
logical name a name thta proceeds left to right from the broadest to most specific term
physical name a short name given to the element limited by the size of the physical database system
category categorize the elements in a broad category such as demographic, health history, symptom...
definition definition of the data element
type character, numerical, date, logical, calculated, free text/memo etc
length the size of the field required to hold values for the data element
decimal a description of the number of decimal places that might be required in a numerical field
domain the description of the allowed values for the data element including the rule for exclusion of invalid data
coding a description of coded values if they are required for the data element
reference a reference for the source that was used to define the data element in the dictionary, if applicable
building the data dictionary step 1: inventory of an existing enterprisestep 2: identifying new data content needsstep 3: consensus development
once standards of data capture and retention are instituted and incorporated into the enterpries data dictionary what must happen? they must be catalogued and distributed to all users of the dictionary.
Created by: thompson_ks