Chapter 7: Indexes, Registers, and Health Data Collection

Indexes Master Patient Index (MPI) The MPI is used administratively for continuity of care internally and externally. Purpose of the MPI - Links a patient’s medical record number with common identification data elements Automated MPI - Consist of an electronic database of the patient’s identification data Manual MPI - Requires typing or handwritten posting of the patient’s identification information Avoiding duplicate MPI records The Master Patient Index (MPI) is the key to locating patient record in numeric identification system. It identifies all patients who have been treated by the facility and lists the number associated with the name. The MPI is maintained permanently. It must contain enough information to identify that you have the correct patient. While the minimum information is the name and number, it really should contain enough information to identify the patient

Disease, procedure, and physicians indexes Disease Index - Organized according to ICD-9- CM codes Procedure Index - Organized according to ICD- 9-CM and/or CPT-4/HCPCS codes Physician Index - Organized according to the numbers assigned by the facility to the physicians who treat inpatients and outpatients Every facility must maintain different indices for data collection, research and process improvement

Registers and Registries Registers and registries contain information about a disease e.g. cancer or an event e.g. a birth Maintained by each healthcare facilities, federal and state government and private organizations. Registers and registries represent a secondary source of information Registries provide surveillance (collection, collation, analysis and dissemination of data). A registry can be established for any disease and can vary by location or type of facility.

Types of Registers and Registries Case report forms Vital statistics Birth certificates Death certificates Operation of registers and registries Register and Registries are operated by a variety of entities including but not limited to: -Federal government agencies (e.g. CDC) -Adoption Registry -Birth defects Registry -Alzheimer Registry

Case Abstracting Case abstracting - an automated or manual process performed by HIM department to collect patient information to determine prospective payment system (PPS) used to report data to quality improvement organizations and state and federal agencies. The following are the processes: Case mix analysis Automated case abstracting systems Manual case abstracting systems Data set Data dictionary Generally with abstracting, a set of predetermined data is obtained from the patient record and related sources. These data items are collected because of their relevance to the disease or condition addressed in the registry. This data provide information such as demographic information, diagnostic information, treatment data, outcomes of treatment, And follow-up.

Health Care Data Sets Before the case abstracting process can begin, standards for collecting and reporting the individual data elements must be established to provide uniformity and easy data interpretation.

Health Care Data Sets Types of Data Sets: Data Elements for Emergency Department Systems (DEEDS) Essential Medical Data Set (EMDS) Health Plan Employer Data and Information Set (HEDIS) Minimum Data Set (MDS) National Cancer Data Base (NCDB)

Health Care Data Sets (Cont’d) Outcome and Assessment Information Set (OASIS) JCAHO ORYX Initiative Uniform Ambulatory Care Data Set (UACDS) Uniform Clinical Data Set (UCDS) Uniform Hospital Discharge Data Set

Health Care Data Sets (Continued) Medical Information Bureau (MIB) Clearinghouse of medical and avocation information National Practitioner Data Bank (NPDB) Legislated by the Health Care Quality and Improvement Act of 1986

Health Care Collection Health data collection is performed by health care facilities for administrative planning and to report statistics to state and federal government agencies. The primary purpose of the health care data is for the care of the patient. Health care data is created by health-related events and are used by many different people, organizations, and agencies for multiple purposes. Users of health data range from the individual patient, the health care providers, and organizations to epidemiologist, researchers, health care payers, grant funding organizations, politicians and public agencies.

Health Care Collection The following are health data collection concepts: Descriptive health care statistics - Summarizes a set of data using graphs, charts and tables. The following are types of descriptive data: Aggregate data Comparative data Patient-centric data Transformed-based data Hospital-based statistics Admission data Length of stay (LOS) Discharge data

Health Care Collection (cont’d) Health care statistics are useful only if developed from quality data General data quality includes: Data integrity Data reliability Data validity The term “data quality” suggests the correctness of the data. As patient records are migrating from paper-based to the HER systems, the characteristics of data quality continue to be refined.

Question Data quality includes: Data integrity Data reliability Data validity All of the above

AHIMA Data Quality Management AHIMA has developed a data quality management model that outlines the characteristics of data quality. The four areas of data quality management are defined by AHIMA as follows: Data Application Data Collection Data Warehousing Data Analysis The AHIMA has published guides on the content of the patient records and professional practice standards for a number of clinical settings. It has also supported the formal development of voluntary standards for EHRs by working with the ASTM, a national standards development body.

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