Health data management across the continuum
Table 1: Completed patient table
|Field Name||Field Type||Field Size||Definition||Allowable Values/ Edits|
|CMS Certification #||Numeric||10||CMC Certification Number of the agency||Ten numbers|
|Branch State||Alpha||2||State where the agency branch office is located||State initials|
|Branch ID #||Numeric||10||Branch ID code, as assigned by CMS||Ten numbers|
|National Provider Identifier||Alphanumeric||40||National Provider Identifier (NPI) for the attending physician who has signed the plan of care||Appropriate identifier|
|Patient ID #||Numeric||20||Agency-specific patient ID used for agency recordkeeping for this episode of care||Twenty numbers|
|Start of Care Date||MMDDYYYY, Numeric||8||Date the first reimbursable service delivered||Futures dates not allowed|
|Resumption of Care Date||MMDDYYYY, Numeric||8||Date of first visit following an inpatient stay by patient currently on service||Futures dates not allowed|
|Patient First Name||Alpha||15||Patient’s first legal name||Forename|
|Patient Middle Initial||Alpha||15||Patient’s middle legal name||Other name|
|Patient Last Name With Suffix||Alpha||15||Patient’s last legal name||Surname|
|Patient State of Residence||Alpha||2||Where the patient is presently residing while receiving home care||Appropriate State initials|
|Patient Zip Code||Numeric||9||Zip code for address where patient is receiving home care||Nine numbers|
|Medicare #||Alphanumeric||8||Medicare Number||Eight numbers|
|Social Security #||Alphanumeric||8||Social Security Number||Eight numbers|
|Medicaid #||Alphanumeric||8||Medicaid Number which specifies the patient’s Medicaid||Eight numbers|
|Birth Date||MMDDYYYY, Numeric||6||Month, day and year of patient’s birth||Futures dates not allowed|
|Gender||Alpha||6||Specifies gender of the patient||M, F|
|Race/Ethnicity||Alpha||9||Specifies groups or population to which the patient is affiliated||B, W, H, A|
|Current Payment Sources for Home Care||Alpha||40||Specifies the present Payment Sources for Home Care||Appropriate sources|
Health record data may be used as primary data source within a healthcare organization since it contains specific data or information that pertains to a particular patient such patient demographics, medications, laboratory data, progress notes and previous medical history. Primary data sources include clinical or medical encounter record. Health record data from uniform data sets may be used for secondary data sources in healthcare policy making. A diabetes Type 1 registry for instance, is a secondary source of data which gathers data relating to the diagnosis of diabetes Type 1 and utilizes it in monitoring patterns of this disease in the United States. Data dictionary is an essential tool because it can be utilized in helping to ensure data accuracy. It provides a descriptive list of attributes, definitions as well as names of data elements that need to be captured within an information system. The objective is to attain data that is consistently defined. Without using data dictionary, there would be a lack of data consistency which could lead to challenges for data comparison as well as reporting, and could also create errors in data use (Zeng, 2008). Thus, data dictionary could greatly improve an organization’s communication across the continuum of care through.
Journal article 1
Lukof, J. Y & Dolin, R. H. (2012). Standards for Computerized Clinical Data: Current Efforts and Future Promise. The Permanente Journal, 6(3): pp. 66-79.
The authors state that data quality is improved by the use of standardized terminologies through better data integration and reusability. According to the authors, standardized terminologies impact how statistical data is collected. This is because they help in clearly defining the problem and provide a sense of context for the gathered data.
Journal article 2
Hammond, W. E. (2012). Call for a Standard Clinical Vocabulary. JAMIA, 4(3): 254-255.
The author asserts that data quality is improved using standardized terminologies through improvements in team communication, and increased utilization of software tools. He also points out that standardized terminologies influence clinical documentation and practice by providing standardized meanings of concepts. According the author, standardized terminologies are important to large health information exchanges since they help in standardizing the meaning of words that are used during health information exchanges.
Journal article 3
Frankel, M., Chinitz, D., Salzberg, C. A., & Reichman, K. (2013). Sustainable Health Information Exchanges. Isr Journal of Health Policy Research, 45(2): 118-122.
The writers point out that data quality is improved by the use of standardized terminologies through facilitation of data exchange with partners, better reusability of data and facilitation of regulatory audits and reviews. They state that standardized terminologies are vital to large health information exchanges because they provide an efficient way of transporting and exchanging data between various systems. They also improve interoperability – exchange and use – of health information.
In a hybrid environment, paper forms would be kept in hard-copy formats and will comprise the definite record that includes fine details such as time and date. It will meet quality measure requirements and serve as a source of truth. The strength of hybrid record is that it saves on cost of converting all the paper records into digital format, and digitized records can be accessed faster (Pizzi, 2012). The weakness is that it takes a lot of time in compiling a complete medical record. This is because one has to go to the system and retrieve electronic documents, and then go and pull out the paper record. Another weakness is failing to identify the single source of truth between the 2 records. When using hybrid records, the legal issues that may arise include difficulties in the legal medical record since healthcare institutions that use hybrid often ask themselves: is the legal record the electronic record or the paper record? (Pizzi, 2012).
The Willow Bend Record Policy protects health information for record storage and destruction of paper and electronic health records basing on the regulation of the state of California – my state. In particular, it is based on the s 72543 Patients’ Health Records legislation. It is also based on the Medicare Conditions of Participation, which basically requires health services suppliers and providers to meet minimum safety and health standards for them to qualify for Medicare reimbursement and certification. However, it is not based on the Health Insurance Portability and Accountability Act which essentially provides protections and rights for participants as well as beneficiaries within group health plan (Centers for Medicare & Medicaid Services, 2014).
Diane’s findings illustrate deficiencies in Willow Bend Hospital’s compliance in the following ways: first, she found the policy that addresses abbreviations and terminology. However, she could not find the person responsible for updating the list and making sure that it is disseminated to every clinical area, carried out in specific time frames and posted in the electronic record system. To correct this deficiency, Diane needs to gather information on staff positions and include staff positions to the policy that addressed the process of auditing health records. The required information on this correction could be found from the management of the Hospital. The other deficiency is that she could not find a policy within her department that addressed backup of electronic information systems. She needs to gather information on a policy that addresses backup of electronic information systems. The required information for this deficiency could be found in the IT policies. Another deficiency is that she did not find a procedural document that described how contract doctors need to manage interruptions with their information workflow in case of an unanticipated power interruption. She needs to gather information on turn-around time for accessing data that is stored within the electronic document management system. The required information could be found on a policy that clearly states how the data could be accessed.
Centers for Medicare & Medicaid Services. (2013). Conditions for Coverage (CfCs) & Conditions of Participations (CoPs).
Pizzi, R. (2012). Hybrid Medical Records an Option for Some Hospitals. Crescent City, CA: CRC Press.
Zeng, X. (2008). Electronic Records in Health Care. N C Med J, 69 (2): 58