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.
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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
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).
One organization that creates and provides standards for healthcare and the implementation of healthcare software is American Society for Testing and Materiel (ASTM). In 2004, ASTM released a standard that would change the interoperability of healthcare software forever. This standard is known as the ASTM E2369, the Continuity of Care Record (CCR) standard. The was first release of CCR was ASTM E2369-4 and was a word document that allowed interoperability between primary care physicians for the exchange of patient summary information (Sween, 2012). The CCR provides “snapshots” of a patient’s administrative, demographic, and clinical information (E31.25, 2012). The information in this snapshot focus on mainly the diagnosis an...
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)
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
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.
There are a number of ways in which patient care can be improved with a facility that utilizes multiple charting systems. The simplest way to provide effective quality care is to implement the EHR. A EHR is an electronic system consisting of a complete patient medical health history of past and current conditions (Keller, 2016; Menachemi & Collum, 2011). In addition, to the patient’s demographic, diagnoses, medications, treatment plans, allergies, laboratory data, immunizations, and test results. EHR decreases medical errors such as misinterpretation of clinical notes, doctors orders, not having access to paper chart that have yet to be filed or has been missed file (Keller, 2016). EHR also allows for quick and easy access to diagnostic test results and patient notes that are needed for patient care. EHR will significantly enhance patient care by reducing the amount of time it takes the healthcare team to retrieve the needed health information to deliver patient care. It will also dramatically reduce medical errors that are associated with the nursing staff manually entering doctors’
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can
If health information technology has been adopted widely, there would be more than $81 billion annually save in the United States only (Gee & Newman, 2013). Despite the vast improvement of health information technology in the current century when compared to the past, there still some challenges in adopting the technology. For example, patients and healthcare providers’ frustration with the current system, and a high cost of the information technology can be mentioned. However, healthcare organizations are thoroughly delivering care, access the patients’ health data, run their analysis for better health outcomes, and gain opportunities to better quality improvement through many electronic health delivery systems (Health information technology, n.d.; Wager, Lee, & Glaser,
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 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.
Health care must be fully accountable for quality and the patient experience is simply the patient's perception of quality. Society should question and debate on how healthcare organizations should show improvement for consumers. This can help organizations create reliable health coverage cost and evaluate medical performances for families and individuals in the future. Physicians and organizations are now evaluating patients with collection of electronic data to improve a patient’s...
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.
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).
Wang , R. Y. (1998) A Product Perspective on Total Data Quality Management. Communications of the ACM, 41(2), 58-65.