Term
| Secondary Health Records and Indexes |
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Definition
these are important for various reasons. They are created as claims, which are used to obtain reimbursement. The claim data is then also used for improving quality and performance. Secondary data may take several forms:
• Indexes, which can be separate files or pointers to data within the primary health records
• Registries, which are usually separate databases created to track specific types of data; for example, cancer tumors, implanted devices, or childhood immunizations
• Custom data sets for reporting performance such as HEDIS or the National Hospital Quality Measures (NHQM). |
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Term
| Internal and External Uses of Indexes |
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Definition
Providers maintain indexes of the data within their patient health records for both internal and external reporting purposes and studies. In a paper record system, indexes were created by manually abstracting data from the patient chart and entering it into a special database. Many EHR systems index data automatically.
Medical records may be indexed by disease, attending physician, surgeon, procedures, discharge status, patient’s age or zip code, or other information. A benefit of coded, fielded data is the ability to automate the creation of an unlimited type and number of indexes.
Indexes may be created to permit internal users of the healthcare organization to locate, count, or analyze the data quickly for quality and process improvement of healthcare operations. Indexes are also used to identify and sort records for external use, such as reporting to health plans or state or federal agencies. Indexes may also be used to identify automatically any records to be abstracted for internal or external registries. |
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Term
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Definition
are separate databases created to track specific types of data. If its used by a hospital to improve performance or processes or to satisfy accreditation requirements, the users are internal. If its used to report data to an outside source, then the users are external. Examples include trauma, cancer tumor, implanted device, and childhood immunizations registries.
An implant registry is an example of a registry created and maintained primarily for internal users that can become essential for reporting in the case of an adverse event, which must be reported to the FDA. |
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Term
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Definition
These are an example of one of the earliest registries, dating back to 1926. The facility-based cancer registrar enters data about cases by abstracting it from the health records of patients diagnosed with some form of cancer. These cases might be identified by using the disease index, discharge reports, or pathology reports or by gathering information for patients registered at outpatient cancer or radiation therapy centers.
Data collected in the facility-based registries is used internally for quality assessment of the facility, for research, and to measure the success of various treatment modalities. The registry data is also aggregated and reported to state and national cancer registries and used to identify trends and changes in the incidence and survival rate for various types of cancers. |
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Term
| Differences between an Index and a Registry |
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Definition
| When records are electronic, an index most often points to a medical record containing one or more fields to be reported or studied. A registry, on the other hand, is a separate database into which certain data elements have been imported or manually entered. For example, a hospital trauma registry would include entries automatically added by selecting cases assigned ICD-9-CM codes in the 800 to 959 range. A disease index, conversely, would include all patients. In addition, the trauma registry might have additional fields that must be completed because they were not in the admission or discharge summary. |
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Term
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Definition
The National Committee for Quality Assurance (NCQA) created the Health Plan Employer Data and Information Set (HEDIS) as a tool by which it could compare the quality of care patients receive under various health plans. HEDIS consists of 71 measures across eight domains of care. Employers can use the results of NCQA reports derived from HEDIS data to select the best plan for their employees. NCQA has an accreditation program for health plans and audits their processes, quality of providers, quality improvement processes, utilization management (UM), and preventive health initiatives.
The NCQA collects HEDIS data directly from managed care HMO and PPO organizations, which transfer data to the NCQA Interactive Data Submission System (IDSS). The data, in XML format, consists of secondary records and does not contain PHI. Researchers are also allowed to use HEDIS data to study trends. |
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Term
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Definition
—National Hospital Quality Measures The Joint Commission’s ORYX initiative was designed to integrate outcomes and other performance measurement data into the accreditation process and support healthcare organizations in their internal quality improvement efforts. These measures were standardized with Centers for Medicare and Medicaid Services (CMS), allowing the facility to collect and report the same data set for the Joint Commission and CMS initiatives. These are called the National Hospital Quality Measures (NHQM).
Hospitals are required to collect and transmit data to the Joint Commission for a minimum of four core measure sets or a combination of applicable core measure sets and noncore measures. The measure sets currently available for selection are acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), pregnancy and related conditions (PR), hospital-based inpatient psychiatric services (HBIPS), children’s asthma care (CAC), Surgical Care Improvement Project (SCIP), and hospital outpatient program quality measures (HOP). Future measure sets are anticipated to include venous thromboembolism (VTE), nursing-sensitive care, and stroke. |
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Term
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Definition
Data analysis includes applying mathematical formulas to produce statistical studies. Not every record has to be included, but for statistics to be meaningful, the number of records, called the sample size, must be large enough to be representative of the whole. If the sample size is too small, the study can result in inaccurate conclusions. The data must also include the type of cases that apply to the measure, but exclude those that are not applicable.
For each measure set, the Joint Commission and CMS have determined the minimum number of cases required to produce statistically valid samples. When a hospital does not have enough cases to meet the minimum, then the sample must include all of the cases meeting the criteria. For example, for the acute myocardial infarction (AMI) measure sets, the minimum sample size is 20 percent of the inpatient population admitted for AMI per quarter. Therefore, if there were 1,500 cases, the sample size would be 300. Where there are fewer than 78 cases per quarter, the sample size must be 100 percent of the cases. To be valid, the minimum AMI sample must be at least 35 cases. Review Figure 11-4 with students |
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Term
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Definition
This is a predefined set of rules that helps to break down complex processes into simple, repetitive steps. It is used to process data to arrive at a desired result. In the case of sampling, an algorithm is used to select the initial population for the measure set. The first step is to evaluate and identify which episode of care records are in the measure set’s population and are eligible to be sampled. This is called the initial patient population from which 20 percent of the cases will be selected. Follow the flow of Figure 11-5 with students to review the flow of logic used in an algorithm.
Once the sample is selected, data that cannot be imported from the hospital’s computer system is abstracted and entered manually from patient records. |
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Term
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Definition
In an effort to improve quality of care, CMS and other payers are developing these programs that tie reimbursement to improvements in quality. The CMS Hospital Quality Initiative links reporting of the National Hospital Quality Measures described earlier to the payments the hospitals receive for each discharge. Hospitals that submit the required data receive the full payment update to their Medicare DRG payments. As of 2009, 98.3 percent of the hospitals eligible to participate were complying with the program.
CMS is also developing pay-for-performance programs for physicians, physician groups, and nursing home care. Recognizing that many of the best opportunities for quality improvement are patient focused and cut across settings of care, CMS is pursuing these programs initiatives to support better care coordination for patients with chronic illnesses. CMS also developed a 3-year pay-for-performance project for physicians to promote the adoption and use of health information technology to improve the quality of care for Medicare patients who are chronically ill. The focus is on small and medium-sized physician practices. Doctors who meet or exceed performance standards established by CMS in clinical delivery systems and patient outcomes receive bonus payments.
Support for these programs has been growing rapidly. As of 2009 more than 150 of these programs programs existed, many using the NCQA measures studied in this chapter. |
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Term
| Name the five factors that affect the quality of primary data. |
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Definition
| Validity, reliability, completeness, timeliness, and security. |
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Term
| How does coded, fielded primary data help in the creation of secondary data? |
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Definition
| It enables the automated creation of indexes. |
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Term
| The text listed nine types of data in a cancer registry. Name three of the types. |
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Definition
| Any three of the following: accession number, patient demographic information, occupational history of patient, datefirst diagnosed, type and site of the cancer, stage of the cancer (size and extent it has spread), diagnostic methodologies, treatment methodologies, and follow-up data. |
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Term
| What does the acronym XML stand for? |
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Definition
| eXtensible Markup Language. |
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Term
| What is the common name for acute myocardial infarction (AMI)? |
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Definition
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Term
| Which type of statistic discussed in this chapter can be used to compare two different things? |
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Definition
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Term
| What is de-identified data? |
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Definition
| Data in which the PHI elements has been removed such that a person cannot be individually identified from the data. |
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Term
| What code set is used to determine the case mix index? |
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Definition
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Term
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Definition
| The process of selecting a subset of the total number of data records using an algorithm. |
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Term
| How is an algorithm defined in this chapter? |
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Definition
| A predefined set of rules that help to break down complex processes into simple, repetitive steps. |
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Term
| Thirty AMI patients who smoked were counseled against smoking; two were not. What is the ratio of AMI smokers who were counseled to those who were not? |
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Definition
| 15:1. (Students may also answer 30:2, but should be advised that ratios are usually reduced to the lowest dominator, in this case 1.) |
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Term
| Integrated systems require HL7 to exchange information with other healthcare systems. |
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Definition
| False: Because integrated systems share a common database they do not require HL7 for internal transactions. |
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Term
| The ADT system registers patients before they are treated or scheduled for treatment. |
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Definition
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Term
| In a general ledger that uses a double-entry bookkeeping system, expenses are amounts that are owed, but not yet paid. |
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Definition
| False: Expenses are money that has been spent, whereas liabilities would be amounts that are owed, but not yet paid. |
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Term
| Accounts payable systems control the outflow of money from a healthcare facility for all expenses except payroll. |
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Definition
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Term
| Rent, insurance, and utilities are all examples of direct costs a department must pay. |
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Definition
| False: These are examples of indirect costs; direct departmental level costs would include things like supplies, materials, and labor directly related to that department’s operations. |
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Term
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Definition
Depending on the vendor, the management and decision support systems discussed in this chapter are either interfaced systems or integrated systems. Interfaced systems are prevalent in hospitals; integrated systems are prevalent in medical offices (called practice management systems).
Interfaced systems consist of separate software and databases that are linked to a computer network and exchange information with other healthcare systems using HL7 or a proprietary transaction standard. The software may be from the same or a different vendor.
Integrated systems share a common database. Data records are read and updated without the need for HL7 transactions. Though programs such as registration and billing use separate software modules, they are supplied by the same vendor and work together seamlessly. |
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Term
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Definition
include financial, human resource, scheduling, and quality management systems. As discussed in earlier chapters, patient registration and billing are two types of administrative systems. In a hospital, the registration system is also called the admission, discharge, transfer (ADT) system, and the billing system is sometimes called the patient accounts or accounts receivable (A/R) system. Think of these two systems as the beginning and end of an episode of care. The ADT system registers patients before they are treated, and the A/R system follows the episodes until the patients’ account balances are zero.
There are many secondary uses for administrative data. Primary administrative data can be used to produce reports such as an aged accounts receivables report that shows how long unpaid balances have been outstanding, or it may be abstracted and exported into a secondary database. |
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Term
| Financial Information Systems |
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Definition
| are used in all types of businesses to track income, expenses, assets, and liabilities. Hospitals and medical practices use financial software uniquely suited to healthcare operations. |
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Term
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Definition
An overall accounting system called the general ledger (GL) is used to produce financial statements and monitor the overall financial health of an organization. In a healthcare facility, the GL typically includes only the daily, monthly, or quarterly totals from the other financial systems.
A standard accounting practice called the double-entry method divides the GL into four categories: income, expenses, assets, and liabilities. Income and expenses are reported on an income statement or profit and loss statement. Assets and liabilities are reported on a balance sheet or statement of financial position. Review Figure 12-2, which shows a sample balance sheet from a nonprofit hospital. |
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Term
| Accounts receivable (A/R) |
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Definition
| is the money that is owed to the business. Patient and insurance billing are the main source of revenue for healthcare organizations of all sizes. A/R and billing data are used, reported, and analyzed by individuals in billing or collections, managers, supervisors, department heads, executives, and officers. Healthcare organizations may also have revenue or accounts receivable unrelated to patient care, such as rental income from an office suite. This revenue is not entered into the patient accounting system, but usually posted directly into the general accounting system or another A/R system. |
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Term
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Definition
| are used to order supplies and services. They keep records of vendors, part numbers, prices, purchase orders, and the ordering department. They can also track the historical prices the facility has previously paid and the current prices for multiple vendors. Large hospitals may have more than one purchasing system. For example, the pharmacy may order separately through a pharmacy ordering system especially suited to ordering drugs. Certain other departments may also order independently, though ultimately all purchases must go through the central purchasing department system to be assigned a purchase order number. |
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Term
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Definition
| manage the disbursement of payments for purchases the facility has authorized, and also manage payments for recurring expenses such as rent, utilities, and insurance and for nonrecurring expenses such as maintenance or repairs. These systems control the outflow of money for expenses (except payroll), print checks, and authorize electronic funds transfers. |
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Term
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Definition
| deals with the administration of employee payroll information and the payment of wages, employer taxes, and employee benefits. Payroll administration deals with the managerial aspects of maintaining a payroll, including managing employee personnel and payroll information; complying with federal, state, and local employment laws; generating reports about payroll activities; and keeping records. Payroll accounting consists of determining federal, state, and local tax coverage rules per employee and other tasks associated with withholding income for tax and benefits purposes. |
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Term
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Definition
| is used to predict expected income and expenses, usually for one year. For hospitals, budgeting typically begins at the departmental level, with each manager or department head preparing a list of goals for the coming year and estimating the costs of achieving those goals. These are then evaluated and included in the overall budget by the CFO. |
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Term
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Definition
| is used to attribute direct and indirect costs to various departments. Direct costs, such as supplies, materials, and labor, are attributed to each department by the hospital’s accounting system. To this, indirect costs (overhead), such as rent, insurance, utilities, managers’ salaries, and so on, are added. |
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Term
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Definition
| use computers to maintain personnel records and to create management reports that track staff productivity, absenteeism, and vacation time; monitor turnover rate; and analyze labor expenses. These functions include: |
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Term
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Definition
| Employee retention, promotions, and incentives are based on employee performance evaluations by managers and on self-assessments. |
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Term
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Definition
| Healthcare employers must train employees in procedures, policies, security, and skills ranging from using the EHR to using a point-of-care testing device. Accreditation by the Joint Commission and CAP requires employee training and certification. |
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Term
| Education and continuing education: |
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Definition
| Most care providers must hold qualified degrees for their field and must be licensed by state regulatory agencies. In addition, care providers must complete a required number of CE hours each year. |
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Term
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Definition
| track immunizations and tests and generate reminders to employees. For instance, the healthcare environment requires regular tuberculosis (TB) tests for all employees; HR systems can keep track of employee compliance. The HR department and the quality management and legal departments use HR programs to track and monitor the occurrence of on-the-job injuries and subsequent workers’ compensation claims. |
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Term
| Patient Scheduling Systems |
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Definition
Outpatient scheduling allows for the orderly examination and treatment of patients. A facility may also use the volume and type of patients scheduled to predict labor and resource needs. Busy medical group practices and hospitals with multiple outpatient clinics often have several employees dedicated to scheduling patient visits, tests, and procedures. Patient scheduling involves considering the reason why a patient has scheduled an appointment and then using that information to determine the appropriate length of time for the appointment. Schedule templates are used to show the user the type and length of appointments that should be scheduled, and empty appointment slots are preset for number of minutes and/or certain types of appointments. Appointment reason codes make it faster for the staff to schedule the appointment and determine the number of minutes required for the appointment based on the reason for the appointment. See Figure 12-5 to view an appointment schedule screen.
Inpatient scheduling consists of processing doctors’ orders for tests or services, coordinating with the respective department, and arranging for an orderly or other assistant to transport the patient from his or her room to the department and back. This may require a schedule coordinator who handles several different departments. A schedule coordinator may also need to schedule events, such as transferring an inpatient to a SNF and the various steps involved in that process. |
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Term
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Definition
are used to schedule which employees are working at what time each day. Hospitals are open 24 hours a day and require sufficient personnel working at all times. Employees are scheduled to work in shifts and may rotate days of the week they work. For example, some RNs work four consecutive days, then have four days off.
The human resources department also tracks and manages vacation schedules, employee sick days, and holidays. Vacation and leave schedules are coordinated by human resources and department managers so that when an employee is gone, another employee is scheduled to perform the vacationing employee’s duties.
Provider scheduling in a medical practice includes blocking doctors’ appointment schedules to indicate times when they will not be in the office and arranging for another doctor to “cover” their patients. Doctors must also be available after hours. Physicians in group practices take turns being “on call.” The practice administrator maintains the on-call schedule.
Surgery scheduling must factor in preparation and transport of the patient (preop), surgery, and recovery (postop). Time must also be allotted between surgeries for the operating room to be cleaned and sterilized. |
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Term
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Definition
covers many areas related to the operation of the hospital and the care provided to patients. QM’s main product is data and reports used for risk analysis and decision support. Facilities use this information to evaluate the appropriateness and effectiveness of medical care.
Quality management systems track and maintain data entered by the QM department and also use and analyze data abstracted from patient health records and other departmental systems. |
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Term
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Definition
| first document patient assessment and utilization management. The case manager identifies appropriate levels of care and considers alternative therapies and resource usage. Utilization management evaluates the case using standard criteria and seeks authorization from the payer. Case management tracks certification, authorization, and concurrent review of the case. It also tracks avoidable days, denials, and appeals |
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Term
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Definition
| are tracked and reported by QM. These include patients admitted with communicable diseases, hospital-acquired infections, and diagnoses that must be reported to the CDC. |
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Term
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Definition
| Includes both patient and nonpatient incidents. Patient incidents might include medication errors, surgical mistakes, or adverse results; nonpatient incidents might include slip or falls by visitors, volunteers, or employees or accidental exposure to toxic or medical waste, to name just a few. Review Figure 12-8, an incident report of a patient falling from bed. Incident reports are always filed and maintained separately from the patient health record in an incident tracking system and are recorded immediately by the employees most familiar with the incident. |
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Term
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Definition
| A hospital patient relations representative or department handles a variety of complaints by patients. The QM department reviews and analyzes each patient relation report to improve care and patient satisfaction and identify patterns or cases that could present a risk to the patient or hospital. |
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Term
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Definition
| Risk can be thought of as any incident or circumstance that might result in a loss, such as property or rights or damage to a person physically, emotionally, or mentally. A hospital’s loss might be financial or a damaged reputation. The goal of risk management programs is to minimize loss by reducing risk through preventive policies and measures. |
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Term
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Definition
Note that peer review in the context of QM should not be confused with the peer review organizations discussed previously in earlier chapters. In QM, peer review is used when a patient, another employee, or an audit of health records has called attention to an issue relevant to patient care. Other providers review the case, procedures, orders, or treatment to determine the appropriateness and make recommendations.
Hospitals and other healthcare entities must report professional review actions that adversely affect a physician’s clinical privileges for a period of more than 30 days to the National Practitioner Data Bank (NPDB). They must also report a physician’s surrender or restriction of clinical privileges while under investigation, and may voluntarily report adverse actions taken against other licensed healthcare practitioners. |
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Term
| Comparative performance measure systems: |
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Definition
| QM also involves comparing performance measures to those of other similar facilities. They may use the NHQM and CMI information available from Medicare, or download data from vendors that contractually provide this service. This allows hospitals to benchmark themselves against the best performers. |
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Term
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Definition
involves analyzing processes and measuring statistical data to identify preventable losses and minimize their occurrence. For example, performing an assessment of computer security to minimize security risks to EPHI data would be an example of risk assessment.
Risk management provides the organization with the information needed to proactively improve performance and processes and provide a safer environment for employees, patients, volunteers, and visitors. The basic functions of risk management are risk identification, risk analysis, loss prevention or reduction, and claims management.
The goal of risk management programs is to minimize loss by reducing risk through preventive policies and measures. For example, the policy of immediately filing incident reports allows management to conduct an immediate investigation of facts surrounding the incident. These facts can significantly improve the legal department’s ability to defend the case should it be necessary to do so. |
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Term
| The Recovery Audit Contractor (RAC) program |
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Definition
is a new CMS initiative that went into effect on January 1, 2010, with the goal of identifying improper payments made on healthcare claims provided to Medicare beneficiaries and obtaining repayment to Medicare. Healthcare providers subject to review under the RAC program include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare Parts A and B.
A key difference between the RAC program and earlier CMS efforts to audit claims is that the recovery audit contractors are private companies that are paid a percentage of what they recover and, therefore, have a strong incentive to identify and recoup overpayments. This makes the risk of financial loss to the hospital or provider more substantial. Hospitals might consider the following when forming a RAC risk management strategy:
• Establish a committee to handle RAC issues.
• Set up a procedure or computer system to track RAC requests and ensure they are handled within the timelines permitted.
• Conduct an internal assessment to ensure that submitted claims meet the Medicare rules.
• Prepare and provision the HIM department to comply with RAC requests.
• Create policies and procedures for deciding which RAC denials to appeal.
For the HIM departments—and even to ensure the fiscal solvency of healthcare organizations—the best strategy for dealing with RAC requests is to ensure that claims are as accurate as possible when first submitted and that requests from the recovery audit contractor are handled efficiently, effectively, and according to procedures and policies that have been put in place well ahead of the RAC requests. |
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Term
A hospital risk management department has received an incident report that a visitor slipped on ice in the hospital parking lot and was injured.
Is this a PCE? |
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Definition
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Term
A hospital risk management department has received an incident report that a visitor slipped on ice in the hospital parking lot and was injured.
What steps should be taken immediately? |
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Definition
| Answer: Determine if the injured person needs medical care. Have the ice removed, salted, or sanded to prevent further incidents. Obtain a list of witnesses to the event. Obtain maintenance records showing when the parking lot was treated for ice. |
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Term
A hospital risk management department has received an incident report that a visitor slipped on ice in the hospital parking lot and was injured.
What structures and processes in the facility should be examined? |
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Definition
| Answer: Determine who has responsibility for how the parking lots are maintained. |
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Term
A hospital risk management department has received an incident report that a visitor slipped on ice in the hospital parking lot and was injured.
What improvements should be made to prevent such accidents in the future? |
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Definition
| Answer: Signs warning visitors to use care when ice is present. Make checking the conditions in the parking lot during winter the duty of a particular department. Establish procedures for ensuring ice conditions are remedied quickly. Use traffic cones or other markers to indicate small patches of unsafe areas or to confine pedestrians to a cleared walk area. |
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Term
A hospital risk management department has received an incident report that a visitor slipped on ice in the hospital parking lot and was injured.
What changes should be made to limit liability for similar events in the future? |
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Definition
| Answer: Ensure parking areas are cleared as soon as possible. Assign security or maintenance personnel to guide and assist visitors when bad weather conditions occur. Consider including a disclaimer of liability on signs that advise pedestrians to use caution. Post signs advising visitors that assistance getting to their vehicles is available on request. |
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Term
| Explain the difference between interfaced and integrated systems. |
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Definition
| Answer: Integrated systems share a common database; interfaced systems are two different systems (sometimes from different vendors) that exchange data. |
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Term
| What general ledger report discussed in this chapter shows income and expenses? |
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Definition
| Answer: Income statement; also called a profit and loss report. |
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Term
| Describe the purpose of an aging report. |
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Definition
| Answer: To monitor the accounts receivable; to know what monies are owed the business for how long, and by whom. |
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Term
| Which of the financial systems is used to track a purchase order? |
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Definition
| Answer: The purchasing system. (Accounts payable is also an acceptable answer.) |
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Term
| Name three types of information tracked by human resource systems. |
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Definition
| Answer: Any three of the following: personnel records; evaluations; employee training, education, and continuing education; staff scheduling; staff productivity; absenteeism; vacation time; employee turnover rate; and labor expenses. |
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Term
| Patient scheduling systems have at least five data elements in common; what are they? |
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Definition
| Answer: Any five of the following: patient, provider, date, start time, reason for visit, estimated length of time required. |
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Term
| What does the acronym PCE stand for? |
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Definition
| Answer: Potentially compensable event. |
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Term
| Name four basic functions of risk management. |
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Definition
| Answer: Risk identification, risk analysis, loss prevention or reduction, claims (against the facility) management. |
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Term
| Name at least three types of reportable incidents. |
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Definition
| Answer: Any three of the following: hospital-acquired infections, medication errors, slips or falls, surgical mistakes or adverse results, accidental exposure to toxic or medical waste or radiation, security problems in or around the facility. |
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Term
| What department abstracts and reports National Hospital Quality Measures? |
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Definition
| Answer: The quality management department. |
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Term
| What is the term for a doctor who must answer calls after hours? |
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Definition
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Term
| Administrative systems do not contain PHI. |
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Definition
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Term
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Definition
| Answer: Cash, property, and things of value that are owned by the business. |
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Term
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Definition
| Answer: Money that is owed by the business, but not yet paid. |
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Term
| How long must a hospital retain copies of the W-4 form? |
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Definition
| Answer: Four years after an employee is terminated. |
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