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Disease index is a listing in dx code number for patients discharged from the faility during a particular time period and physician name
Operation index is arranged in numerical rder by patient's prcedure code(s) using ICD codes, with surgeon name.
MPI, a permanent record, contains patient indentifiable data such as name, address, DOB, dates of hosptialization r encounters, name of attending physician, and health record number.
4 basic files
Cancer Registry Master index: Alphabetical listing of all pateints in the cancer registry index
Accession registry is a permanet log of all cancer patients entered in fo the data base chronological by date of Dx.
Accession number is used to
Case definition defines the cases that are to be in it.
Case finding is a methd used to identify the patients who have been seen and/or treated in the facility for particular disease or condition of interest to the registry.
Follow up period , permanetnt file, updated annaully or on most recent visit.
Computer-Based Patient Record
Defined by the IOM, an CPR is an electronic patient record that resides in a system, specially designed to support users by providing accessibiity to complete and accurate data, alerts, reminders, clinical desicion support systems, links to medical knowldge, and other aids.
Electronic Health Record / EHR
System that generally considered on that captures data from any number of computer systems in a healthcare organization and is used in at the point of care to support clinical decision making.
consolidating and storing data from various databaes throughout the enterprise, used to perform data analiysis rather than support routine operations. (Johns 909)
Intergrated vs Interfaced
Integrated - Multiple components working together as one system
Interfaced - stand-alone components but tied into a larger system
Input & Output devices
- Input devices are such as keyboards, microphones, scanners etc.
- Output devices printers, faxes, and speakers. (Johns 897)
OS consist of master programs, called the supervisor, that manage the basic operations of the cmputer.
Application software is used to produce documents, specialit needs, education and enertainment uses.
Programming languages helps people interact with and instruct computers
Programming language generation
Generation 1 - machine = consisted of Ones and Zeros
Generation 2 - assembly = uses set abbeviations, but not portable
Generation 3 - high-level = uses words and arithmatic phrases, COBOL & BASIC
Generation 4 - Very high-level = SQL report builder, and SPPS
Generation 5 - natural = (AI) artificial interllegence users to speak to, ex. LUNAR
UNIX & JAVA
LAN & WAN
Local Area Network connects computers in a relatively small area, within one rom or one building.
Wide Area Netowrk connects devices cross a large geographical area, ex.. across the state or even the world.
is an programmed coolection of data saved as a binary-type file on a computer. Ability to perform muliple tasks.
Types of DBases:
2. Object oriented
3. Object relational
Relational - stores data in prefdefined tables that cntain rows and columns similar to a spreadsheet.
Object oriented - stores objects of data. is discrete or abstract thing such as a care or a line at the grocery
- Object relational - combines both traditional data Currency, intergers etc..) and advanced data types (graphix, movies etc).
- (Johns 902)
Column/field - basic category info
Row/record - collection related data info
Primary key - is a number that is a one-up counter or a randomly generated
Foreign key - is a column of one table that corresponds to a primary key in another table., allowing two tables to join.
Patient Care management
Data collected at one point of care can be used at various points of care.
used to automate the nursing process frmo assessment to evaluation, including patient care decision support, management applications, nursing educational and research
streamline the dispencing of medications, control inventories, automatically compare drugs orders appropriate for patient and provide information needed.
- that can generate, analyze and manage images.
- PACs picture imaging systems, are being used on xrays, MRI, mammograms...
Clinical decision support
systems that include order entry, results reporting, electronic documentation, medication prescribing and admin
Administration IS: (Johns 955)
Human Resources mgt
Pateint mgt -
Financial mgt - includes payroll, AP/AR, billing and cost accounting, budgeting etc...
Human Resources mgt - maintains records, and create reoports
Materials mgt - puchasing and inventory control, barcoding, tracking supplies
Facilities mgt - helps plan, organize, manage, and maintain physical facilities.
Management Support Systems (Johns 879)
Executive decision making
Planning & marketing
Executive decision making - helps provider make decsions about patinet, and comply with clinical practices guildlines
Financial modeling -
Planning & marketing - indentifies and assisting priortities to the various, upgrades and changes that might be make din an organization's ISs
Resource allocation -
Expert systems - is a knowledge system built from a set of rules applied to specific problems.
Information Security (Johns 983)
Confidentiality - act of limiting disclosure of private matters
Privacy - right of individuals to keep information about themselves being disclosed to anyone
Security - to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, desturciton or loss.
Accredited Standards Committee
EHR - is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations.
Access control - refers to exerting control over who can interact with a resource.
Accredited Standards Committee (X12N) - 12N standards include transactions for claims/encounters, attachments, enrollment, disenrollment, eligibility, payment/remittance advice, premium payments, first report of injury, claim status, referral certification/authorization, and coordination of benefits.
Audit trail - record of all transictions in the system
Authentication - confirmation of truth
CCHIT - Certified program is an independently developed certification that includes a rigorous inspection of an EHR’s integrated functionality, interoperability and security using criteria developed by CCHIT’s broadly representative, expert work groups.
HL7 - HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic health information. The 2.x versions of the standards, which support clinical practice and the management, delivery, and evaluation of health services, are the most commonly used in the world.
Daily inpatinet census
Census - A census is the procedure of systematically acquiring and recording information about the members of a given population.
Daily inpatient census - The daily census is the number of patients present at census taking time, plus any patients who were admitted after the previous census-taking time and discharged before the next census-taking time.
3 Measures of Central Tendency (Johns p529)
Mean = sum of all values in distribution
Median = is midpoint of the frequency
Mode = is the simplest measure of central tendency
data statistics of births, deaths, marraiges, and divorces
Health Care Delivery System
Quality assurance -
Health Care Delivery System - organization of all health care facilties, providers, and ancillary services necessary to directly serve patients
Accessibility - is the ease with which a patient has access to a health care facility
Availability - the ease with which patients can use medical resources
Catastrophic health Inc.
- HMOs require members to select a primary care physician (PCP), a doctor who acts as a "gatekeeper" to direct access to medical services.
- PPO is a membership that allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization.
Catastrophic health Inc. - health benefits that provide protection against the high cost of treating severe or lengthy illnesses or diseases
Accreditation is a voluntary process in which certification of competency, authority, or credibility is presented.
Licensure - process by whoich a governmental authority grants permission to an practitioner to operate in a/an organization or profession.
Certification refers to the confirmation of certain characteristics of an object, person, or organization. This confirmation is often, but not always, provided by some form of external review, education, assessment, or audit.
Capitation - It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
- RBRVS - Resource-based relative value scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all Health maintenance organizations (HMOs).
- RBRVS assigns procedures performed by a physician or other medical provider a relative value which is adjusted by geographic region (so a procedure performed in Manhattan is worth more than a procedure performed in Dallas). This value is then multiplied by a fixed conversion factor, which changes annually, to determine the amount of payment.
DRG - DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital
A prospective payment system (PPS)
- is a means of determining insurance payments based on predetermined prices, commonly from Medicare.
- Payments are typically based on codes provided on the insurance claim.
Examples of these codes include:
Diagnosis-related groups – for hospital inpatient claims
Ambulatory Payment Classification – for hospital outpatient claims Current
Procedural Terminology – for other outpatient claims
TEFRA was created in order to reduce the budget gap by generating revenue through closure of tax loopholes and introduction of tougher enforcement of tax rules, as opposed to changing marginal income tax rates.