Chapter 2 - Information Integrity and Data Quality Flashcards
primary data source
data derived from the original source of information, such as the patient encounter as recorded by the healthcare professionals involved
secondary data source
data derived from a primary data source; essentially, they are sources that make it possible to analyze data from primary sources, one example being a cancer registry that identifies what kinds of cancers are present in a state and how many cases there are
data capture
the process of recording healthcare-related data in an electronic health record system or clinical database
direct data entry
Any number of manual data entry methods such as keyboard, mouse, or other devices for entering data into the information system (IS). A number of data field types are available for use in an IS. Some of these field types can contribute to data quality by limiting the number of choices, by limiting the appropriate entries, and further specifying the data required.
hot spot
also known as a pop-up text; it is a type of help message that is triggered when the cursor is placed on top of a data field
unstructured data fields
data fields that use data elements that allow for free text entry, which means that the user can type in any data that he or she chooses
structured data fields
data fields that guide the user during the data entry process, limiting what a user can enter into the field
template based data entry
A cross between unstructured and structured data entry. The user can pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. It assists the healthcare provider by providing direction in what is to be documented.
speech recognition
also known as voice recognition; it is technology that translates speech to text
front-end speech recognition (FESR)
speech recognition where the one dictating is also the one who edits the document afterwards; more accurate but can take time away from seeing patients in the case of physicians
back-end speech recognition (BESR)
the specific use of speech recognition technology in which the physician dictates in the traditional manner and an editor (someone else) listens to the audio and reviews the document created to ensure it was created correctly
natural language processing (NLP)
the technology that converts human language (structured or unstructured) into data that can be translated then manipulated by information systems
data quality
the reliability and effectiveness of data for its intended uses in operations, decision making, and planning
data integrity
the extent to which healthcare data are complete, accurate, consistent, and timely
edit check
also referred to as an edit test; something that checks data entered into a data entry system for validity (e.g. cannot give a patient an impossibly high body temperature such as 254 degrees)
data quality management
the business processes that ensure the integrity of an organization’s data during collection, application (including aggregation), warehousing, and analysis
data accessibility
the extent to which data items are easily obtainable by authorized users
aggregation
the formation of a number of things into a cluster
quantitative analysis
a review of the health record to determine its completeness and accuracy. It is used by health information management (HIM) professionals as a method to detect whether elements of the patient’s health record are missing. In quantitative analysis, the reviewer determines whether or not the reports are present or absent from the health record.
qualitative analysis
a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care. While reviewing a health record, the reviewer considers whether the health record appropriately documents the care provided.
concurrent
existing, happening, or done at the same time
data comprehensiveness
a standard that means that the patient’s health record must be complete, meaning that all required data are included
physician advisor (PA)
Someone hired by the healthcare organization to act as a liaison between the HIM department or others and the patient’s physician. The PA reviews health records for various reasons, including qualitative reviews, utilization reviews, quality reviews, surgical case and tissue reviews, other pathological reviews, and a host of blood and laboratory reviews for various medical staff and hospital committees. Typically, several physicians serve as PAs on an annual basis and are usually from diverse backgrounds, such as pathology, surgery, medicine, and other disciplines so that reviews can be a true peer review.
data consistency
a standard that ensures that like data are the same on each document or computer screen. For example, in the paper health record, the patient’s date of birth is listed on many different documents. It is easy for someone to write the wrong age on a document, which would create different ages on different documents. With the EHR, the date of birth is entered once and is displayed on multiple screens.
data currency
(currency as in current, not as in money) a standard that ensures that data are up to date. A data value is up to date if it is current for a specific point in time, and it is outdated if it was current at a preceding time but incorrect at a later time. Patient care must be provided based on current information. For example, a patient’s chest x-ray study from six weeks ago has little to no value when a physician is treating the patient’s pneumonia. The physician needs a current chest x-ray study to evaluate the patient’s current condition.
data definition
the specific meaning of a healthcare-related data element
data granularity
the level of detail at which the attributes and values of healthcare data are defined. The required level of detail depends on the circumstances of the patient’s care. For example, the documentation in the health record for a patient who is being treated for cardiac disease will describe the patient’s cardiac condition in much more detail than if the patient had a disease in another body system.
data precision
how consistent data results are when measurements are repeated
data relevancy
the extent to which healthcare-related data are useful for the purposes for which they were collected
data timeliness
a standard that means that data should be recorded in an appropriate period of time after the event and should be available to the user when needed
data cleansing
also called data scrubbing; the process of checking internal consistency and duplication as well as identifying outliers and missing data, and correcting any issues. In other words, data cleansing means looking for errors or problems with the data, such as duplicate patients, and addressing the discrepancy so that the errors can be corrected.
outliers
an extreme statistical value that falls far outside the normal range. For example, if a research study has captured the number of continuing education hours that RHITs report and most reported somewhere in the range of 20 and 250 hours but one reported 1,500 hours, then the 1,500 hours would be an outlier. An outlier is not necessarily an error, but it should be evaluated for accuracy because of the impact that it has on the mean and other statistical analysis of the data.
data mapping
the process of extracting data fields from one or multiple source files and matching them to their related target fields in the destination
addendum
an item of additional material, typically omissions, added at the end of a book or other publication
patient identification error
an error that occurs when patient A’ s health information is accidentally documented in patient B’s health record
