HM480

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Health Information
Management: Concepts,
Principles, and Practice
Sixth Edition
Chapter 6
Data Management

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Data and Data Sources
• Primary data source: Patients’ health records
• Secondary data source: Registries and other
databases
• Patient-identifiable data: Data that can be linked to
a specific individual
• Aggregate data: Data on groups of individuals that
do not identify specific individuals
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Users of Secondary Data
• Internal Users
• Medical staff
• Administrative staff
• Management staff
• External Users
• Researchers
• Public health agencies
• State and federal databases
• Local governments collecting vital statistics such as birth
and death rates
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Facility-Specific Indexes
• Master patient/population index
• Disease index
• Operation index
• Physician index
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Registries Defined
• Disease registries: Collections of secondary data
related to patients with a specific diagnosis,
condition, or procedure
• Case definition: Description of the cases to be
included in a disease registry
• Case finding: Process of identifying patients who
have been treated for the condition defined as the
subject of the registry
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Registries
• Cancer registries
• Trauma registries
• Birth defects registries
• Diabetes registries
• Implant registries
• Transplant registries
• Immunization registries
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Cancer Registries
• Facility-based registries
• Population-based registries
• Case definition and case finding
• Data collection
• Accession numbers and accession registries
• Demographic information
• Staging systems
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Cancer Registries
• Reporting and follow-up
• Standards and agencies for approval
• American College of Surgeons
• North American Association of Central Cancer Registries
(NAACCR)
• Centers for Disease Control and Prevention (CDC)
• Education and certification for cancer registrars
• Certified Cancer Registrar (CTR)
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Trauma Registries
• Case definition and case finding
• Data collection
• Abbreviated injury scale (AIS)
• Injury severity score (ISS)
• Reporting and follow-up
• Standards and agencies for approval
• American College of Surgeons
• Education and certification for trauma registrars
• Certified Specialist in Trauma Registry (CSTR)
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Birth Defects Registries
• Case definition and case finding
• Data collection
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Diabetes Registries
• Case definition and case finding
• Data collection
• Reporting and follow-up
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Implant Registries
• Data collection
• Reporting and follow-up
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Transplant Registries
• Case definition and case finding
• Data collection
• Reporting and follow-up
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Immunization Registries
• Case definition and case finding
• Data collection
• Reporting and follow-up
• Standards and agencies for approval
• Centers for Disease Control and National Immunization
Program
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Other Registries
• Registries may be developed for any type of disease
or condition
• Examples of emerging registries include
• HIV/AIDS
• Cardiac
• Gastroenterology
• Sudden unexpected infant death (SUID)
• National Provider Identifier (NPI)
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Database Management and Design
• Relational Databases
• Conceptual, logical, and physical design
• Entity Relationship Modeling
• Entity, attributes, and relationships
• Database Implementation
• Structured Query Language (SQL)
• NoSQL Data Model
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Healthcare Databases
• National and state administrative databases
• Medicare Provider Analysis and Review File (MEDPAR)
• National Practitioner Data Bank (NPDB)
• State administrative databases
• National, state, and county public health databases
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Healthcare Databases
• National Health Care Survey
• National Hospital Care Survey (NHCS)
• National Survey of Ambulatory Surgery
• National Nursing Home Survey
• National Home and Hospice Care Survey
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Healthcare Databases
• Vital statistics databases: births, deaths, fetal
deaths, marriages, and divorces
• Clinical trials databases
• ClinicalTrials.gov
• Health services research databases
• Agency for Healthcare Research and Quality (AHRQ)
• Healthcare Cost and Utilization Project (HCUP)
• National Library of Medicine
• Medical Literature, Analysis, and Retrieval System Online
(MEDLINE)
• Unified Medical Language System (UMLS)
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Processing and Maintenance of Secondary
Databases
• Manual versus automated methods of data
collection
• Vendor systems versus facility-specific systems
• Data security and confidentiality issues
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Trends in the Collection of Secondary Data
• Increased use of automated data entry
• More stakeholder involvement in national policy
regarding secondary data
• HIM role in stewardship of secondary data
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Data Quality
• Data quality standards
• MRI Principles of Healthcare Documentation
• AHIMA Data Quality Model
• Data quality requirements
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Data Dictionaries
• Types
• Database management system
• Organization-wide
• Development guidelines
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