Secondary Data Sources The health record’s primary purpose is patient care and reimbursement for encounters. In order to see trends in a population of patients, you look at the data that is extracted from the records and enter it into databases – registries, indexes, etc. These data sources are referred to as secondary data sources. HIM Roles in Managing Secondary Records and DatabasesEstablishing database: Determining content of database Ensuring compliance with laws, regulations, and accreditation standards Data dictionary Data steward: oversees that data put in database or registery is accurate and complete Differences Between Primary and Secondary Data Sources Primary data source: medical record… b/c it contains information about a patient that has been documented by a healthcare professional Secondary data source: data contained in indexes, registries and similar databases Ways to classify data: Patient-specific/identified data Patient identified within the data. Every fact recorded in the record relates to a patient by name. Patient identifiable data If identify of patient can be derived or inferred from the data with or without the assistance of a computer. Can the patient be identified by date of birth, phone #, zip code, Aggregate data Data on groups of patients without identifying any particular patient individually Purposes and Users of Secondary Data SourcesFour major purposes to collect secondary data: Quality, performance, and patient safety Research – data entered into databases help researchers determine treatment plans Population health – require information be reported about certain diseases to prevent spreading Administration – facilities are required to check physicians in the national database for information on previous malpractice or action against the physician Internal Users Users within the organization Examples: Medical staff, Management staff Identify patterns and trends that are helpful in patient long term care, benchmarking with other facilities. External users Individuals and institutions outside the facility Examples: State data banks, Federal agencies Federal government collects data from states on vital events like births and deaths Types of Secondary Data Sources Facility-specific indexes: enable health records to be located by diagnosis, procedure, physician. Originally kept on cards, now in computerized databases due to technology. Broken down into several types… let’s discuss those types! Master Population /Patient Index (MPI) Disease and Operation Index Physician Index Registries Purpose: to collect data from health records and to make them available for users Registries contains more extensive information than indexes. Index reports created using data from existing facility databases. Registries contain more extensive data from the patient record. Each registry must define the cases that will be included: case definition Case finding used to identify the patients who have bee.

1. Secondary Data Sources
The health record’s primary purpose is patient care and
reimbursement for encounters.
In order to see trends in a population of patients, you look at the
data that is extracted from the records and enter it into
databases – registries, indexes, etc.
These data sources are referred to as secondary data sources.
HIM Roles in Managing Secondary Records and
DatabasesEstablishing database:
Determining content of database
Ensuring compliance with laws, regulations, and accreditation
standards
Data dictionary
Data steward: oversees that data put in database or registery is
accurate and complete
Differences Between Primary and Secondary Data Sources
Primary data source: medical record… b/c it contains
information about a patient that has been documented by a
healthcare professional
Secondary data source: data contained in indexes, registries and
similar databases
Ways to classify data:
Patient-specific/identified data
Patient identified within the data. Every fact recorded in the

2. record relates to a patient by name.
Patient identifiable data
If identify of patient can be derived or inferred from the data
with or without the assistance of a computer. Can the patient be
identified by date of birth, phone #, zip code,
Aggregate data
Data on groups of patients without identifying any particular
patient individually
Purposes and Users of Secondary Data SourcesFour major
purposes to collect secondary data:
Quality, performance, and patient safety
Research – data entered into databases help researchers
determine treatment plans
Population health – require information be reported about
certain diseases to prevent spreading
Administration – facilities are required to check physicians in
the national database for information on previous malpractice or
action against the physician
Internal Users
Users within the organization
Examples: Medical staff, Management staff
Identify patterns and trends that are helpful in patient long term
care, benchmarking with other facilities.
External users
Individuals and institutions outside the facility
Examples: State data banks, Federal agencies
Federal government collects data from states on vital events like

3. births and deaths
Types of Secondary Data Sources
Facility-specific indexes: enable health records to be located by
diagnosis, procedure, physician. Originally kept on cards, now
in computerized databases due to technology.
Broken down into several types… let’s discuss those types!
Master Population /Patient Index (MPI)
Disease and Operation Index
Physician Index
Registries
Purpose: to collect data from health records and to make them
available for users
Registries contains more extensive information than indexes.
Index reports created using data from existing facility
databases.
Registries contain more extensive data from the patient record.
Each registry must define the cases that will be included: case
definition
Case finding used to identify the patients who have been treated
in a facility for a particular disease
Virtual Field Trip
Using Patient Registries to Improve Healthcare Quality
http://www.youtube.com/watch?v=_3ZPZ0EKVCE

4. Example: Cancer RegistriesFacility-based registries:
Provide information for improved understanding of cancer
(diagnosis, treatment)Population-based registries:
Identifying trends and changes in the new cases of cancer
within the area covered by the registry
Registry required to collect data such as:
Demographic info about each cancer case
Occupational history of individual
Pathological data about the cancer (site, stage, type of
treatment)
Example: Data Collection for Immunization RegistriesPatient
nameBirth dataSex, race, ethnicityBirth orderBirth
state/countryMother’s nameVaccine typeVaccination
dateVaccine lot number
National Practitioner Data BankDatabase of medical malpractice
payments, adverse licensure actions and certain professional
review actionsRequired reporting:
Information on practitioner
The reporting entityPenalties for non-reportingData used in
credentialing processhttp://www.npdb-hipdb.hrsa.gov/
Healthcare Integrity and Protection Data BankMandated by
HIPAA to report healthcare fraud and abuseFinal adverse
actions are reported:
Federal or state licensing and certification actions
Exclusions from participation in federal or state healthcare
programs
Any other adjudicated actions or decisions defined in the

5. HIPDB regulations
Healthcare Cost and Utilization Project (HCUP)
Started in 1988
Our most comprehensive source of hospital care data
Data collected from these types of encounters: in-patient stays,
ambulatory surgery and services visits, and emergency
department
Includes clinical and nonclinical data (diagnoses and
procedures, discharge status, patient demographics, and
charges) for all patients, regardless of payer (e.g., Medicare,
Medicaid, private insurance, uninsured)
Enables researchers, insurers, policymakers and others to study
health care delivery and patient outcomes over time
Family of databases, software tools and related products
Data is used for research on health policy issues:
cost and quality of health services
medical practice patterns
access to health care programs
outcomes of treatments at the national, State, and local market
levels.
Direct quote taken from:
https://www.ahrq.gov/research/data/hcup/index.html
Healthcare Datasets and Information ManagementVirtual Field
Trip: https://www.youtube.com/watch?v=IDM-
Vd2iyGg&nohtml5=False