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 innumeric identification system. It identifies all patients who have beentreated by the facility and lists the number associated with the name. TheMPI is maintained permanently. It must contain enough information toidentify that you have the correct patient. While the minimum informationis the name and number, it really should contain enough information toidentify the patient

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 outpatientsEvery facility must maintain different indices for data collection, research and process improvement

Disease, procedure, and physicians indexes

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). Aregistry can be established for any disease and canvary 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 processperformed by HIM department to collect patientinformation to determine prospective paymentsystem (PPS) used to report data to qualityimprovement organizations and state and federalagencies.

The following are the processes: Case mix analysis Automated case abstracting systems Manual case abstracting systems Data set Data dictionaryGenerally with abstracting, a set of predetermined data is obtained from the patient record and related sources. These data items arecollected because of their relevance to the disease or condition addressed inthe registry. This data provide information such as demographicinformation, diagnostic information, treatment data, outcomes of treatment, And follow-up.

Health Care Data Sets

Before the case abstracting processcan begin, standards for collectingand reporting the individual dataelements must be established toprovide uniformity and easy datainterpretation.

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 thecare of the patient.Health care data is created by health-related eventsand are used by many different people, organizations,and agencies for multiple purposes. Users of healthdata range from the individual patient, the health careproviders, and organizations to epidemiologist,researchers, health care payers, grant fundingorganizations, 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 ifdeveloped from quality data

General data quality includes: Data integrity Data reliability Data validity

The term “data quality” suggests thecorrectness of the data. As patient records aremigrating from paper-based to the HER systems,the characteristics of data quality continue to berefined.

Question

Data quality includes:a. Data integrityb. Data reliabilityc. Data validityd. 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 thepatient records and professional practice standards for anumber of clinical settings. It has also supported the formaldevelopment of voluntary standards for EHRs by working withthe ASTM, a national standards development body.

QUESTIONS?????