Ch 4 PP

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Chapter 4: Healthcare Data Sets
and Standards
Health Information Management
Technology:
An Applied Approach
Fourth Edition

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Introduction
• Data
o Data element
• Information
• Aggregate data

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History of Healthcare Data Collection
• Bills of Mortality
• Modern data standardization began in 1960s
o Hospital discharge abstract systems
o Data sets

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Data Sets in the Electronic Environment
• Original data sets inadequate for electronic
environment
• Healthcare informatics standards

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Data Sets
• List of recommended data elements with uniform
definitions that are relevant for a particular use

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Importance and Use of Data Sets
• In 1960s NCHS and NCVHS coordinated effects
to create data sets
• Two purposes
o Identify data elements to be collected on each patient
o Uniform definitions for common terms
• Data sets do not limit what data can be collected

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Importance and Use of Data Sets
• Used for
o Research
o Clinical trials
o Quality
o Safety improvement
o Reimbursement
o Accreditation
o Exchanging clinical information

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Types of Data Sets
• Data sets required or recommended by the
federal government
o Uniform Hospital Discharge Data Set (UHDDS)
• Short-term general hospitals
• Collected from every hospital inpatient
• Required by federal government
• Used in DRGs
• Data elements listed in figure 4.1

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Uniform Ambulatory Care Data Set
• Patients depart from facility on same day
• Includes physician offices, outpatient hospital
clinics and diagnostic services and more
• Reasons for decrease in inpatient hospitalizations
o Technological advancements
o Third-party reimbursement for outpatient services
o Medicare prospective payment system (PPS) limits

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Uniform Ambulatory Care Data Set
• Some data elements similar to UHDDS
• Specific ambulatory data elements
o Reason for encounter
• Optional data elements
o Living arrangements
o Marital status
• See figure 4.2
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Uniform Ambulatory Care Data Set
• Goal of UACDS is to improve data comparison
• Provides uniform definitions that help analyze
patterns of care
• Recommended by federal government
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Minimum Data Set for Long-Term Care
and Resident Assessment Protocols
• Used in long-term care
• Mandated by Medicare and Medicaid
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Minimum Data Set for Long-Term Care and
Resident Assessment Protocols
• Three components
o Minimum Data Set for Long-Term Care–
Version 3.0
o Care Area Assessment process
o RAI utilization guidelines

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Minimum Data Set for Long-Term Care
and Resident Assessment Protocols
• Core set of screening and assessment elements
• Completed at admission and periodically
thereafter
• Far more extensive than other data sets
• Used to create resident assessment protocol
• Used to assess resident safety and quality
improvement

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Outcomes Assessment Set
• Collects core data on Medicare home
health patients
• Used in measuring patient outcomes
• Used as basis for home health reimbursement
• Determines if patient can be discharged or
transferred from home care.

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Healthcare Effectiveness Data and
Information Set
o Sponsored by National Committee for Quality
Assurance
o Used to compare performance of managed
healthcare plans
o Collects administrative, claims and health record
review data

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Healthcare Effectiveness Data and
Information Set
• Basis of performance improvement efforts
for health plans
• Develops physician profiles
• Abstracted from health record in hospitals
and clinics
o Combined with enrollment and claims data
• Population-based data collection tool
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Data Elements for Emergency Departments
• Published by the Centers for Disease Control
• Support uniform collection of data in
hospital-based emergency departments
• Recommends both content and structure of
data elements
• Utilizes national standards for electronic
data interchange

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Data Elements for Emergency
Departments
• Incorporates national standards for electronic
data interchange
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Joint Commission Core Measures
for ORYX
• ORYX integrates outcomes data and other
performance measures
• Promotes comprehensive, continuous,
data-driven accreditation process

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Joint Commission Core Measures for
ORYX
• Core measures based on selected
diagnoses/conditions
o Example: Diabetes

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Data Sets for Interoperative Electronic
Information Exchange
• Meaningful use requires submission of
information on clinical quality measures
• Health Information Technology Expert Panel
o Quality Data Model
• Defines concepts used in quality measures and clinical care
• Automates structured data capture in EHR and other systems
• QDM element

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Data Sets for Interoperative Electronic
Information Exchange
• ASTM International identified core data set for
patient’s clinical summary
o Continuity Care Record
o See figure 4.3
• Health Level 7 (HL7)
o Clinical Document Architecture.
• Exchange model for clinical documents
• Documents are machine readable
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Data Sets for Interoperative Electronic
Information Exchange
• Continuity of Care Document
• Transition of care initiative
o Clinical information model
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Standards for Electronic Data and
Electronic Data Interchange
• UHDDS, UACDS, and others were designed for
paper records
• New standards are being developed for the EHR
o EHR development
o Interoperability
o Information exchange

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Definition of Data Standard for Electronic
Data Exchange
• Data standard provide acceptable values for
data fields
• Data exchange standards are protocols that
ensure data transmitted from one system to
another remain comparable
• Transmission standards support format and
sequence of data during transmission

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HIPAA Administrative Simplification
• Standardized information exchange
• ANSI ASC X12N
o Current version 5010
• Code sets

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Data Needs in an Electronic Environment
• Must be able to integrate data from multiple
systems
o Internal and external

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Benefits of Data Exchange Standards
• Describe accepted methods for collecting,
maintaining and/or transferring healthcare data
among computer systems

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Standards Provide Common Language
That is Used to
• Exchange information
• Share information
• Communicate within and across disciplines and settings
• Integrate disparate data systems
• Compare information at a regional, national, and
international level
• Link data in a secure environment

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This ability allows for
• Disease surveillance
• Health and healthcare population monitoring
• Outcomes research
• Decision making and policy development

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Benefits of Data Exchange Standards
• Many standards required to implement EHR
• Infrastructure supports
o Connectivity
o Interoperability
o Seamless data interchange
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American Recovery and Reinvestment Act
• Made ONC a permanent office
o Help develop national health IT infrastructure
• Provided funds for standards, health information
exchange and implementation assistance
• Established standards, implementation
specifications and certification criteria for
certification of EHR technology

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Health Information Technology Policy
Committee and HIT Standards Committee
• HIT Policy Committee
o Recommends to the National Coordinator on a policy
framework for the development and adoption of a
national health information technology infrastructure
• HIT Standards Committee
o Recommends to the National Coordinator on
standards, implementation specifications and
certification criteria for electronic exchange and use
of health information

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Standards Development, Coordination,
Testing, and Harmonization
• Standard supports business process and
o Be agreed upon by group of experts
o Be publically vetted
o Provide rules, guidelines, or characteristics
o Help ensure materials, products, processes, and
services are fit for their intended purpose
o Be available in an accessible format
o Be subject to ongoing review and revision process

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Harmonization
• Process of replacing standards and policies
adopted by nations with uniform global
standards
• Refers to information technology standards
• Standards development organizations
o HL7
o ASTM
o ANSI
• Coordinates development of other SDOs

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Types of Standards
• Structure and content standards
o Uniform definitions of data elements
o Examples
• American Society for Testing and Materials International
Standard E1384-02a07
o Content and structure for EHR
• HL7 EHR-S Functional Model and Standards
o Exchange, integration, sharing, and retrieval of
electronic health information

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Type of Standards
• Content Exchange Standards
o Provide rules of how data are transmitted
o Examples
• Continuity Care Record
– Relevant current and past information about health status and
treatment
• Clinical Document Architecture
– Exchange model for clinical documents
• Continuity of Care Document
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Institute of Electrical and Electronics
Engineers 1073
• Open systems communications in healthcare
applications
o Beside medical devices and healthcare sysetms
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Digital Imaging and Communication
in Medicine
• Permits interchange of biomedical image form
forms and related information
• Interoperability messaging standard for imaging
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Vocabulary Standards
• Include vocabularies, code sets, and
nomenclatures
• Vocabulary standards provide common
definitions for medical terms
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Privacy and Security Standards
• Implemented throughout healthcare
• Protects personal health information
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Emerging Health Information Standards
• Extensible Markup Language (XML)
o Universal language to facilitate storage and
transmission of data published on the Internet
o Metadata Standards
oMetadata
oSupports descriptive data that characterize other data to
provide clearer understanding

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Role of HIM Professional
• Conducting data content standards requirements
analysis
• Developing local data dictionary to support
enterprise-wide interoperability
• Advancing the development of data content
standards
• Contributing to domain knowledge by participating
in relevant professionals association work
• Contributing to the development and harmonization
of industry and professional standards