Types of Data Collection for Healthcare
In any healthcare organization, data is collected in numerous ways for an ever-increasing number of reasons. Data may be collected by a monitoring device directly connected to the patient, or by providers as they make observations or record treatments. Quality improvement activities often call for data collection where observations of activities, timeliness, or satisfaction indicators are gathered. Data may be abstracted from primary sources and collected for unique reporting requirements, such as specialized registries or claims transactions. With the various types of data collected in many different methods for varied purposes, it is not surprising that data collection may have escaped management in the past.
Why Is It Important?
Data collection should be carefully managed in healthcare organizations. Time spent collecting data can consume huge portions of a provider's day -- taking him or her away from more direct patient care activities. Other employees may spend their entire day collecting data. When you consider the cost of data collection equipment, software, employee time, benefits, and other overhead, the price of data collection can add up quickly. And what are you getting for your money? Is the data collected reliable? Is it comprehensive? Does it provide the necessary detail to answer important clinical and business decisions? For the price your facility is paying, the answers to these questions must be yes.
AHIMA's data quality management model depicts data collection as one of the four primary data functions. The others are application, warehousing, and analysis. All characteristics of data quality management should be applied to data collection ...
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...me, as well as the type of discharge. In order to have them complete the required discharge information, they were trained on the definitions of discharge status in the Uniform Discharge Data Set and instructed on the consequence of data error on payment and outcome reporting.
In order to reduce the data collection time for evaluation of record completion, the director of health information management worked with the operating room staff to capture the results of their preoperative check of record completeness. By improving the data collection tool and standardizing the definitions between the two applications, they were able to concurrently collect information about completeness of history and physicals, preanesthesia assessments, and consent completion -- eliminating a redundant review of information post discharge.
Bibliography:
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The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
Many new technologies are being used in health organizations across the nations, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 The Centers for Medicaid and Medicare Services (CMS), instituted a EHR incentive program called the Meaningful use Program. This program was instituted to encourage and expand the use of the HER, by providing health professional and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and medicaid," 2014). The Meaningful use program will be explored including its’ implications for nurses, nursing, national policy, how the population health data relates to Meaningful use data collection in various stages and finally recommendations for beneficial improvement for patient outcomes and population health and more.
The world of healthcare changes every day. Technology, as we know it evolves and changes the actual care that patients receive and even post care as well. It has been determined that most faults are caused by system failures. When a break in the system has occurred it must then be decided where the,” inefficiencies, ineffective care and preventable errors” to then influence changes within the broken system (Hughes, 2008). Improvements sometimes can begin with measurements and benchmarks which in turn will allow organizations to assess the trouble spots and broken areas within the system. Many times those broken areas within the system will be owned by the humans who operate within these systems. According to the Institute of Medicine (IOM)
...f clinical information systems in health care quality improvement. The Health Care Manager. 25(3): 206-212.
In reviewing patient charts with the data from the patient monitors, we have been able to determine when we have not had complete documentation. This may have occurred when the patient was off the unit or was undergoing a
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
With Stage 2 Meaningful Use the amount of data collected on patient’s increases as well as its use for coordinating and communicating care with the patient and other providers.
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
The American Health Information Management Association is a body of health information professionals that majorly concerns itself with the improvement of the quality of medical records (Harman 104). These health data records are vital for the purposes of monitoring the progress of patients, performance improvements and for improving outcomes.
The first acute care facility that I first visited was Adirondack Medical Center located at 2233 state Route 86 in New York City (Bruneau et al., 2007). The data that they deal with include the number of surgical diagnoses that occur in the acute care facility. The other challenge that they face is that which involves the relation of the charges that is charged in the care facility and the charges at the national level. The information on the number of patients that acquire nosocomial infections is also another type of data that the information management professionals encounters on the job.
Physicians and organizations are now evaluating patients with electronic data collection to improve a patient’s care.... ... middle of paper ... ... References Nembhard, I. M., Alexander, J. A., Hoff, T. J., & Ramanujam, R. (2009). Why Does the Quality of Health Care Continue to Lag?
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
Healthcare is constantly changing with the intention of improving patient care. The Institute of Medicine (IOM) issued a report introducing five core competencies for health professionals, in order to improve the Untied States healthcare system: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics (Institute of Medicine of the National Academies, 2003). IOM proposes that if all five core competencies are utilized by health professionals, quality patient care can be achieved. The facility in which this nurse work, is in need of improving their charting system. The facility currently utilizes two different software systems for charting, in addition to
For these reasons, some measures are suggested in the literature to improve the quality of data entry (De Lusignan, Liaw et al. 2011). Moreover, it is suggested that electronic healthcare data should be validated before its use in research (Bayley, Belnap et al. 2013).
In the health care industry, gathering information in order to find the best diagnosis route or even determine patient satisfaction is necessary. This is complete by conducting a survey and collecting data. When the information is complete, we then have statistical information used to make administrative decision within the healthcare field. The collection of meaningful statistics is an important function of any hospital or clinic.