Secondary Data Sources

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Secondary Data Sources

Secondary Data Sources

CAHIIM Competency: Subdomain I.E. Secondary Data Sources

  • Validate data from secondary sources to include in the patient’s record, including personal health records

Preparation: Read the Processing and Maintenance of Secondary Databases section of Chapter 6 in the Oachs and Watters text. (Page 191-193 in the 5th edition)

While the reading focusses on data from patient health records being abstracted or moving electronically into secondary data source systems, more and more we are having to consider data from secondary data sources being used to add to the primary health record. Examples:

  1. A patient brings in their personal health record that contains health information from 2 other primary care providers at local clinics. They want this information added to their health record at your hospital.
  2. Inbound HIE data from an earlier encounter from an unrelated provider is electronically received for a patient’s health records
  3. Inbound data from the patient portal is received many times a day as patients update their demographic or insurance information on the patient portal
  4. Data is received from smart devices such as ambulatory heart monitors or insulin monitors and is downloaded into patient records

It would be inefficient for all of this inpatient data to be manually checked for validity. Please describe in 2-3 paragraphs (400-500 words, 1-2 pages, APA format with a title page, body, and references) how a healthcare organization could assure that this incoming data is valid and accurate. Be sure to specifically address how systems would be set up, as well as standards and policies that would need to be set.  Please use reputable references, and ensure you have 3 or more from professional organizations, .gov sources, or peer-reviewed journal articles.

Health-care Quality-Measurement Data Sources

 

It’s helpful to know what kinds of data you’ll need to produce the scores for each quality measure before you determine which ones to report. 
It’s possible that the information you’re looking for already exists since it was gathered by someone else. 
Report sponsors, on the other hand, may be required to gather data on their own in some situations.

 

Data can be gathered from a variety of sources, such as medical records, patient surveys, and administrative databases used to pay bills or administer care, depending on the measure. 
Each of these sources has a different primary function, thus when used for quality assessment and reporting, there are benefits and drawbacks.

 

Data collected by the government

 

Organizations collect administrative data about the demographics of the population they serve, as well as their use of services and charges for those services, typically at the level of individual users, in the course of providing and paying for care. 
Claims, encounters, enrollment, and provider systems are all used to compile the data. 
Type of service, number of units (e.g., days of service), clinical diagnostic and procedure codes, service location, and amount billed and reimbursed are all common data items.

 

Administrative Data Has Benefits

 

Electronically available.

 

Getting data from medical records is less expensive.

 

Available to the whole patient population and across all insurance companies.

 

Coding techniques and procedures that are quite uniform (and improving).

 

Administrative Data’s Challenges

 

There is a lack of clinical data.

 

Because the main objective is billing, the accuracy of public reporting is questionable.

 

Completeness.

 

Timeliness.

 

Medical Charts for Patients

 

A patient’s medical history and care are documented in a medical record. 
Patients’ files are now more accessible thanks to the development of electronic medical records. 
The convenience and affordability of using this data for quality measurement and reporting should improve as electronic medical record systems become more widely used.

 

Medical Records Are Beneficial

 

Clinically comprehensive.

 

Providers think it’s trustworthy.

 

Medical Records’ Constraints

 

When patients obtain treatments from multiple locations, the cost, complexity, and time it takes to gather data, especially if a different record format is employed.

 

Most records are now kept on paper, requiring experienced personnel to manually abstract data.

 

Surveys of patients

 

Patients’ self-reported information regarding their healthcare experiences is collected through survey questionnaires. 
Reports on the care, service, or treatment received are among the topics covered, as are perceptions of the care’s outcomes. 
Typically, surveys are sent to a random sample of patients via mail, phone, or the internet.

 

Patient Surveys Have Benefits

 

Patients are the finest source of certain types of information.

 

Survey design and administration methodologies that have been proven.

 

The results of the survey are simple to comprehend and relate to.

 

Patient Surveys’ Difficulties

 

Administration fees for surveys.

 

If questions are poorly written, survey administration processes are not standardized, the sampled population is not representative of the entire population (sampling bias), or the population is not represented in the responses, there is a risk of misleading results (response bias).
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