Health Care Data Sets

HTH 1304, Health Information Technology and Systems 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

4. Differentiate various health information standards in terms of their ability to support the requirements of a health care enterprise. 4.1 Explain how standardized health care data sets impact interoperability between health care

institutions. 4.2 Summarize regulations governing health care data sets. 4.3 Explain the differences between administrative data sets and clinical data sets.

5. Identify health information technologies necessary for effective data storage and use in health care

organizations. 5.1 Define a standardized health care data set. 5.2 Describe three specific health care data sets used in the health care industry.

Course/Unit Learning Outcomes

Learning Activity

4.1 Unit Lesson Chapter 2 Unit II Essay

4.2 Unit Lesson Chapter 2 Unit II Essay

4.3 Unit Lesson Chapter 2 Unit II Essay

5.1 Unit Lesson Chapter 2 Unit II Essay

5.2 Unit Lesson Chapter 2 Unit II Essay

Required Unit Resources Chapter 2: Collecting and Storing Health Care Data

Unit Lesson In the United States, managing health care data is one of the more important responsibilities in the medical field as it impacts many different areas of the industry. Having access to health care data can serve many purposes, such as allowing for quality care to be delivered to patients, assisting in submitting claims for medical billing and reimbursement, and using for legal references. Organizations such as the Centers for Disease Control and Prevention (CDC), the National Center for Health Statistics (NCHS), and the World Health Organization (WHO) use patient health care data to get statistical baselines that help them identify disease trends and better manage and predict health epidemics (Centers for Disease Control and Prevention, n.d.; World Health Organization, n.d.).The research that can be done using health care data can improve the overall health of the population and help develop initiatives that will promote healthier lifestyles and create more efficient health care providers. The health data records that are used to gather these statistics are void of name, so the identities of the patients are not known. This would be an example of secondary data as it

UNIT II STUDY GUIDE

Collection of Health Data

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has altered for research purposes. Secondary data can also be used in billing and reimbursement as well as other specific organizational initiatives. A primary record would be the record created by the care provider that all patient information. Health care data can be separated into a variety of categories to better help classify and organize the data. Electronic Health Records (EHRs) contain much more patient specific information than just clinical data regarding the patient’s care. Demographic information such as the patient’s age, sex, and ethnicity can be important when determining the level of care a patient receives and how that care is provided. Not only is demographic information important for the delivery of patient care, it can also be useful in tracking diseases. For example, by having patients’ addresses, statistical professionals can physically map the occurrence of certain diseases or illnesses that may help them narrow the causes of the diseases or give them more insight on how to combat the diseases. Other types of patient-specific data could include financial information, administrative information such as hospital identification data, and socioeconomic information such as occupation, income, or habits such as smoking. A good example of how socioeconomic data can help health care analysts would be the relationship that could be inferred from coal miners and lung disease. A coal miner’s lung disease could be the direct result of his or her profession, and trending this data can forecast how the disease may progress in a given area. Probably the most important type of health care data, and the majority of a patient’s record, would be clinical data, as it is directly related to the patient’s diagnosis, testing, and plan of care. This information can range from patient vital signs to medication orders to surgery procedures. Many of the departments within a health care institution utilize clinical data, and it is imperative for certain departments to have an efficient line of communication with one another. A few departments that need to have this relationship would be the emergency room, radiology, and the laboratory. If a patient is in the emergency room and needs an x-ray, that patient’s health information along with any other pertinent details would be sent to the radiology department staffers so they have all the data they need. Most of this communication is done electronically, so instant transmission of information can be achieved. Moreover, laboratories communicate with many units in a health care institution as they receive specimens to test for diagnostic purposes. While these departments communicate with each other by the transmission of clinical data, the “language” that is spoken will vary and may be specific to the departments involved. This coordination involving the use defined groups of information, or data sets as they are called, is beneficial to fostering an environment of effectiveness and conciseness across the medical industry. Data sets are groups of characters arranged in ways that assist entities in the classification, comparison, and analysis of specific health information. Laboratories may use one particular data set while an inpatient rehabilitation facility may use a different data set. The goal of this collection and reporting of data sets is for health care providers to only use information that is relevant, which, in turn, streamlines processes and reduces confusion. The textbook describes a good example of data sets relating it to online shopping. When you are ready to check out after selecting an item for online purchase, normally, there are multiple sections you need to fill out such as billing address, credit card number, name, shipping address, etc. The shipping crew in that business’s warehouse may not need to know that customer’s credit card or billing information, and they will only pay attention to the data set containing the name and shipping address. Along the same premise, a medical lab may not pay much attention to imaging from radiology if their task is to test a patient’s blood. Data sets help keep health care providers organized and on the same page with other units interested in similar information. This is important for not only helping doctors and other health care professionals make better medical decisions but also for keeping statistical health data uniform and consistent. There are various specific data sets that are used in the health care industry today. Some of these data sets are setting-specific, meaning they were developed with particular departments and/or settings in mind to directly assist in the reporting, transmission, and analysis of information. Some of the data sets that are used in health care include the Minimum Data Set (MDS 3.0), Data Elements for Emergency Department Systems (DEEDS), Outcome and Assessment Information Set (OASIS), Uniform Hospital Discharge Data Set (UHDDS), and Uniform Ambulatory Care Data Set (UACDS), to name a few (Davis & LaCour, 2017). The Uniform Hospital Discharge System has about 20 components all designed to better serve patients admitted to the hospital for inpatient care. An outpatient facility would not use UHHDS, nor would it use the Minimum Data Set. The Minimum Data Set was designed for skilled nursing facilities such as long-term nursing care centers, assisted living centers, and other health care facilities that specialize in continuous care (Davis & LaCour, 2017).

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One area in health care that is expected to grow tremendously is home health care. Between now and 2025, millions of Baby Boomers will become Medicare age and will begin to use the health program they have paid into (Centers for Medicare & Medicaid Services, n.d.-a). With this increase, the need for home health professionals who assist patients with daily tasks or administer medical services in the convenience of the patient’s home will arise. The Outcome and Assessment Information Set (OASIS) will be the data set that will be used to report information from the home health sector of the medical industry (Centers for Medicare & Medicaid Service, n.d.-b). There are hundreds, if not thousands, of data sets in operation in the health care industry, and they all have a specific area of specialization. While this lesson only touched on a few setting specific data sets, remember that there are data sets that are illness- or disease-specific, which should give you an idea of how many data sets there may be. Health care data is not only collected industry-wide but is also collected on the clinical level. When an individual visits a health care facility, it is to have a health issue looked at by a professional so that he or she can assess and provide treatment for the problem. The physician goes through a process known as medical decision-making to diagnose the patient and initiates a plan of action based on the data collected from the patient. The format physicians use to evaluate patients is called SOAP, which is an acronym for subjective, objective, assessment, and plan. Please see the table below for explanation of each part of a SOAP report (Davis & LaCour, 2017):

References

Centers for Disease Control and Prevention. (n.d.). National Center for Health Statistics: Resources for students and librarians. https://www.cdc.gov/nchs/nchs_for_you/students.htm

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Centers for Medicare & Medicaid Services. (n.d.-a). National health expenditure projections 2016-2025. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends- andReports/NationalHealthExpendData/Downloads/proj2016.pdf

Centers for Medicare & Medicaid Services. (n.d.-b). Outcomes and assessment information set (OASIS).

https://www.cms.gov/Medicare/Quality-Initiatives-Patient- AssessmentInstruments/OASIS/index.html

Davis, N., & LaCour, M. (2017). Foundations of health information management (4th ed.). Elsevier. World Health Organization. (n.d.). About WHO. http://www.who.int/about/en/

Learning Activities (Nongraded) Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information. Chapter 2: Competency Milestone and Critical Thinking Questions, pp. 59 and 60