Chapter 2:

Health Care Data

 Topic Learning Outcomes (TLOs)
At the end of the lecture, students will be able to:

TLO1: Define health care data and information.

TLO2: Explain the major purposes for maintaining patient records.

TLO3: Discuss basic patient health record and claims content.

TLO4: Discuss basic uses of health care data, including big and
small data and analytics.

TLO5: Identify common issues related to health care data quality.

2
Basic Terminology……

What is Data
What is Data Element
What is Information
What is Knowledge

3
What is Data?
• ‘Representation of real world facts, concepts or instructions in a
formalized manner suitable for communication, interpretation or
processing by human beings or by automatic means’.

• Examples of data are:

 4
 Black
 Right leg
 Pneumonia
What is Data?
• Data have no meaning until put into context.
• either relating one item of data to another, or by putting data into a
‘field’ or ‘data element’.

CONTEXT DATA

Age at admission 4

Hair colour Black

Site of wound Right leg

Diagnosis Pneumonia
What is Data Element?

• ‘The descriptive name of the information object that contains data.

A unit of data for which the definition, identification, representation
and permissible values are specified by means of a set of attributes’.
whereby
• Information is technically not the same as data. Information is
defined as: ‘data that are interpreted, organized and structured’.
The difference –
Data, Data Element & Information
• For example:

Zakuan is four years old. This is information that can be

applied to an individual instances; it is something that a
fact about a given person or circumstance’.
LEVEL EXAMPLE

Data 4

Data element Age at admission ‘4’

Data in a person’s record Zakuan’s record shows his

(information about Zakuan) ‘Age at admission’ to be ‘4’
What is ‘Knowledge’?

• ‘an information that has been synthesized so that

interrelationships are identified and formalized’.
• An example of such synthesis is the knowledge that children
under five are more susceptible to influenza virus. This
knowledge can be applied:

Zakuan is more susceptible to influenza virus than an adult

would be.
What is ‘Knowledge’?
• Other examples
• medical knowledge generated from evidence-based medical practice, such as
the knowledge that smoking cigarettes is a risk factor for contracting throat
cancer.

• To use data in health systems with accuracy, one must understand both the item of
data and how it is represented, and the data element within which it is stored.

• The way in which we capture and store data items has an affect upon their ability to
be computer-processed and upon the quality of the data.

• Knowledge is a “combination or rules, relationships, ideas, and experience” (Johns,

1997)
In conclusion…the differences

• Data are symbols or observations reflecting differences in the

world. Example = 250.00 (Note: data is the plural of datum)

• Information is data with meaning. Example = ICD-9 code of 250.00

means type 2 diabetes

• Knowledge is information that is justifiably believed to be true.

Example = obese patients are more likely to develop type 2
diabetes
In conclusion…the differences
• Data can be aggregated into a variety of formats such as image
files (JPG, GIG, PNG), text files, sound files (WAV, MP3) or video
files (WMV, MP4)

• Recognize that these formats do not define what information is

available, just the category format

• Data is the domain of computer scientists, but information is the

domain of informatics and informaticians
In conclusion…the differences

• Information retrieval involves both computer science

(data) and informatics (information).
 Data and Information
• Computer data not only lacks meaning, but must includes dates and
other qualifiers to gain significance. For example, blood glucose =
127. Was that mg/dl, was the sample drawn fasting, etc.

• Everything must be standardized, otherwise computer B will not

understand data transmitted from computer A (i.e. data won’t be
interoperable)
Information to Knowledge
• A modern way to convert medical information to knowledge is to
use a clinical data warehouse (CDW)

• EHRs are now a huge source of healthcare data and information.

They contain both structured (coded e.g. ICD-9 codes) and
unstructured text (free text or natural language)

• Interpreting free text requires natural language processing (NLP)

 Clinical Data Warehouse
• Data from EHRs, Radiology, Pathology, etc. are copied into a staging database
where they are cleaned and loaded into another common database and
associated with meta data (data that describes data). ICD-type data is an
example of meta data

• Tools can be applied to the data in the CDW, such as simple descriptive
analytics that reports the number of patients with breast cancer, their age,
menopausal status, etc.

• CDWs do a better job of analyzing and reporting aggregate healthcare data

than the average EHR, which tends to focus on the individual
 Clinical Data Warehouse
• CDWs can be used to evaluate a critical clinical process, cost
estimates and they can analyze potential solutions

• CDWs are highly valuable for informatics and evidence based

medical research

• CDWs can help track infections and report trends to public health
Clinical Data Warehouse

ETL = extract,
transfer and
load
From Data to Knowledge

Health Care

Processing
Knowledge

Health Care
Information

Health Care
Data
HEALTH CARE DATA AND INFORMATION
SOURCES
• The majority of health care information generated and used in HCIS
within/across organisations can be found as an entry in a patient's
health record or claim, and this can be easily linked to a specific,
identifiable patient.
• Health information is defined as any information, whether oral or
recorded in any form or medium, that does the following:
• Is created or received by a health care provider, a health plan, a public health
authority, an employer, a life insurer, a school or university, or a health care
clearinghouse.
• Relates to an individual's past, present, or future physical or mental health or
condition, the provision of health care to an individual, or the payment for the
provision of health care to an individual.
 Protected Health Information (PHI) 19
Medical Record versus Health Record

• Electronic medical records (EMRs) are a digital version of the paper

charts. An EMR contains the medical and treatment history of the
patients in one practice (or organization). EMRs have advantages over
paper records. For example, EMRs enable clinicians (and others) to do
the following:
• Track data over time
• Easily identify which patients are due for preventive screenings or checkups
• Check how their patients are doing on certain parameters—such as blood
pressure readings or vaccinations
• Monitor and improve overall quality of care within the practice
20
Medical Record versus Health Record

• Electronic health records (EHRs) do all those things - and more.

• EHRs focus on the total health of the patient - going beyond standard
clinical data collected in the provider’s office (or during episodes of
care) - and is inclusive of a broader view on a patient’s care.
• EHRs are designed to reach out beyond the health organization that
originally collects and compiles the information. They are built to
share information with other health care providers (and
organizations), so they contain information from all the clinicians
involved in the patient’s care
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Patient Record Purposes

Records support not only managing a single episode of care but also
a patient’s continuum of care and population health (Episode of
care)

1. Patient care - provide the documented basis for planning

patient care and treatment
2. Communication - means by which healthcare providers,
whether within a single organization or across organizations,
can communicate with one another about patient needs
3. Legal documentation – court case evidence
4. Billing and reimbursement - provide the documentation
patients and payers use to verify billed services 22
Patient Record Purposes

5. Research and quality management - used in many facilities

for research purposes and for monitoring the quality of care
provided

6. Population health - used to monitor population health, assess

health status, measure utilization of services, track quality
outcomes, and evaluate adherence to evidence-based
practice guidelines

7. Public health – health agencies use information from patient

records to inform policies and procedures to ensure that they
23
protect citizens from unhealthy conditions
Personal Health Records

• An increasingly common type of patient record, maintained by

the individual to track personal health care information

• “is a tool . . . to collect, track and share past and current

information about your health or the health of someone in your
care.” – AHIMA

• Does not constitute a legal document of care, but it should

contain all pertinent health care information contained in an
individual’s health records

24
Patient Record Content

General overview of record content:

• Identification Screen.
• The information on the identification screen of a health/medical record is
obtained during registration or admission.
• The identification data includes the patient's name, address, phone
number, insurance carrier, and policy number, as well as the patient's
diagnoses and disposition at discharge.
• The physicians record these diagnoses, which are then coded by
administrative personnel.
• The data identification component is used as a clinical and administrative
document.
25
Patient Record Content

General overview of record content:

• Problem list.
• Patient records frequently contain a comprehensive problem list, which
identifies significant illnesses and operations the patient has
experienced.
• This list is generally maintained over time. It is not specific to a single
episode of care and may be maintained by the attending or primary care
physician or collectively by all the health care providers involved in the
patient’s care.

26
Patient Record Content

• Clinical Data – History and Physical Examination

• Usually the History and Physical Examination is prepared as one

handwritten or transcribed report, which assists the physician in
establishing a diagnosis on which to base treatment and serves as a
reference for future illness.

• The history documents the patient’s chart complaint, history of present

illness (HPI), past/family/social history (PFSH), and review of systems
(ROS).
History and Physical
Examination

Sample History
Description and Documentation
Examples for Elements of Patient
Patient Record Content

• Clinical Data – History and Physical Examination

• An interval history documents a patient’s history of present illness and

any pertinent changes and physical findings that occurred since a previous
inpatient admission if the patient is readmitted within 30 days after
discharge for the same condition. The original history and physical
examination must also be made available to the attending physician (e.g.,
a copy filed on the current inpatient chart or the previous discharged
patient record available on the unit.)
Patient Record Content

EXAMPLE
Patient is discharged from the hospital with the diagnosis of acute
asthmatic bronchitis. Within 30 days, the patient is readmitted for
the same condition. In this situation, it would be appropriate for
the attending physician to document an interval note that
specifies the patient’s present complaint, pertinent changes, and
physical findings since the last admission.
After the history is completed, the physician performs a physical
examination which is an assessment of the patient’s body system.
History and Physical
Examination

Sample Physical Examination Report

History and Physical
Examination

Documentation Examples for

Elements of Physical Examination
Patient Record Content

• Clinical Data – History and Physical Examination

• A physical examination of the patient’s body is necessary to assist in

determining a diagnosis, documenting a provisional diagnosis, which may
include differential diagnoses.

• A differential diagnosis indicates that several diagnoses are being

considered as possible. The physician also summarizes results of pre-
admission testing (PAT) (e.g., blood tests, urinalysis, ECG, X-rays, and so
on).
Patient Record Content

• Progress Notes contain statements related to the course of the

patient’s illness, response to treatment, and status at discharge. They
also facilitate health care team members’ communication because
progress notes provide a chronological picture and analysis of the
patient’s clinical course – they document continuity of care, which is
crucial to quality care.
Clinical Data – Progress
Notes
• As a minimum, progress notes
should include:
 An admission note
 Follow-up notes and
 A discharge note

Sample Progress Notes

Clinical Data – Progress Notes

Progress Notes
Patient Record Content

• Clinical Data – Progress Notes

• The frequency of documenting progress notes is based on the

patient’s condition (e.g., once per day to 3 or more times per
day)

• The progress Notes are usually organized in the record

according to discipline (e.g., each discipline, such as physical
therapy, has their own section of progress notes
Patient Record Content

• Clinical Data – Progress Notes

• Some facilities adopt integrated progress notes, which means all progress
notes documented by physician, nurses, physical therapist, occupational
therapist, and others are organized in the same section of the record.

• This allow the patient’s course of treatment to be easily followed because

a chronological “picture” of patient information is presented.
 Face Sheet

EXAMPLE
2/24/YYYY Less weak. Walking without instability or pain.
Patricia Smart, M.D.

2/25/YYYY Patient very much improved. To start patient walking more.

Patricia Smart, M.D

2/25/YYYY Very upset and unable to rest all night due to his demented and
very noisy roommate.
Patricia Smart, M.D

2/27/YYYY Patient states he feels good. Clear to decrease Valium to 5 mg.

Slept last night without sleeping capsule.
Patricia Smart, M.D
Patient Record Content

• Clinical Data – Consultation Report

• A consultation is the provision of health care services by a

consulting physician whose opinion or advice is requested by
another physician.
• A consultation report is documented by the consultant and
includes the consultant’s opinion and findings based on the
physical examination and review of patient record.
Patient Record Content

• Clinical Data – Consultation Report

• To initiate a consultation, the attending physician:
• Documents a physician order requesting consultation with a particular
doctor
• Documents a progress note that outlines the reason for consultation
• Contacts the consulting physician to discuss the patient’s case and to
agree to the consultant’s role in patient care, if any

• As part of the consultation process, the consulting physician:

• Reviews the patient’s record
• Examines the patient
• Documents pertinent findings
• Provides recommendations and/or opinions
Clinical Data – Consultation Report

Sample Consultation Report

Patient Record Content

• Physician Orders (or doctor orders)

• direct the diagnosis and therapeutics patient care activities

(e.g., medications and dosages, frequency of dressing
changes, and so on).
Physician Order

Sample Consultation Report

Sample Physician Orders Physician Orders

Patient Record Content

• Ancillary Reports

• are documented by such departments as laboratory, radiology

(or X-ray), nuclear medicine, and so on – they assist
physicians in diagnosis and treatment of patients.
Clinical Data – Ancillary Reports

Ancillary Reports
Clinical Data – Ancillary Reports

Laboratory Report Radiology Report

Clinical Data – Ancillary Reports

Electrocardiogram Electroencephalogram
(EKG or ECG) (EEG)
Clinical Data – Ancillary Reports

Electromyogram (EMG) Blood Transfusion Report

Patient Record Content

• Clinical Data – Operative Report

• The Operative Report (or operative record) describes gross

findings, organs examined (visually or palpated), and
techniques associated with the performance of surgery. It is
to be dictated immediately following the operation and
authenticated by the responsible surgeon.
Clinical Data – Operative Report

Sample Operative
Report
Patient Record Content
• Clinical Data – Operative Report
• Documentation elements include:
• Principal participations (e.g., surgeon, assistant surgeon, anesthesiologist, and
so on)
• Pre- and postoperative diagnosis
• Surgical procedure performed
• Anesthesia administered
• Detailed evidence that surgically acceptable techniques were used
• Indications for surgery
• Condition of the patient (pre-, intra-, and postoperatively)
• Detailed description of the operative procedure performed (e.g., surgical
techniques), including organs explored
• Description of operative findings, unique elements in the course of procedures
performed, any unusual events that occurred during the procedure, and
specimens removed
• Description of other procedures performed during operative episode
• Documentation of ligaments sutures, number of packs, drains, and sponges
used
Patient Record Content

• Clinical Data – Pathology Report

• The Pathology Report (or tissue report) assists in the diagnosis

and treatment of patients by documenting the analysis of
tissue removed surgically or diagnostically (e.g., biopsy), or
that is expelled by the patient (e.g., products of conception).
Clinical Data – Pathology Reports

Contents of the pathology

report include:

• Date of examination
• Clinical diagnosis
• Tissue examined
• Pathologic diagnosis
• Macroscopic
examination
• Microscopic
examination
• Authentication by
pathologist
Patient Record Content

• Clinical Data – Discharge Summary

• The discharge summary (or clinical resume) documents the

patient ‘s hospitalization, including reason(s) for
hospitalization, course of treatment, and condition at
discharge.
Clinical Data – Discharge Summary

Sample Discharge Summary

Patient Record Content

• Clinical Data – Discharge Summary

• Contents of a discharge summary include:
• Patient and facility identification
• Admission and discharge dates
• Reason for hospitalization (brief clinical statement of chief complaint
and history of present illness, HPI)
• Significant findings, including pertinent laboratory, X-ray, and
pathological findings – negative results may be as pertinent as positive
• Treatment provided (medical and surgical), and patient’s response to
treatment, including any complications and consultations.
Patient Record Content

• Clinical Data – Discharge Summary

• Contents of a discharge summary include:
• Condition on discharge, as stated in specific measureable terms
relative to condition on admission, avoiding use of vague terms such as
improved (in addition, presence and status of drains, wounds, and
sutures should be noted)
• Instructions to patient and/or family (relative to physical activity;
medication , diet, and follow-up care)
• Authentication by attending physician
Claims Content

• In general, the accounting or billing department of a health care

organisation is in charge of processing claims, which includes
verifying insurance coverage, billing third-party payers, and
processing payments as they come in.
• With the nearly universal adoption of electronic billing and
government-mandated (in US) transaction standards, standard
claims content has become essential.
• Claims Content  health care data and information sources
Diagnostic and Procedural Codes
• Diagnostic and procedural codes are captured during the patient
encounter, not only to track clinical progress but also for billing,
reimbursement, and other administrative purposes.
• This diagnostic and procedural information is initially captured in
narrative form through physicians’ and other health care providers’
documentation in the patient record, which is subsequently translated
into numerical codes.
• Two major coding systems are employed by health care providers
today:
• ICD-10 (International Classification of Diseases)
• CPT (Current Procedural Terminology), published by the American
Medical Association
HEALTH CARE DATA USES
• Health care data must be stored and retrieved before it can be
used.

• How do we obtain that data so that it can be aggregated,

manipulated, or analysed by health care organisations in order to
improve patient care and business operations?

• How do we combine this patient care data created and stored

internally with other pertinent data from external sources?

• In this section, we will focus on the use of data analysis to 61

HEALTH CARE DATA USES
Regardless of the scope of the data or the tools used, health care
data analysis requires basic elements.
• First, there must be a source of data, for example, the EHR,
claims data, laboratory data, and so on.
• Second, these data must be stored in a retrievable manner, for
example, in a database or data warehouse.
• Next, an analytical tool, such as mathematical statistics,
probability models, predictive models, and so on, must be applied
to the stored data.
• Finally, to be meaningful, the analyzed data must be reported in
a usable manner.
62
Databases and Data Warehouses
• A database generally refers to any structured, accessible set of
data stored electronically; it can be large or small. The back end of
EHR and claims systems are examples of large databases.
• A data warehouse differs from a database in its structure and
function.
• In health care, data warehouses that are derived from health care
information systems may be referred to as clinical data repositories.
• The data in a data warehouse come from a variety of sources, such as the
EHR, claims data, and ancillary health care information systems (laboratory,
radiology, etc.).
• The data from the sources are extracted, “cleaned,” and stored in a
structure that enables the data to be accessed along multiple dimensions,
such as time (e.g., day, month, year); location; or diagnosis.
63
• Data warehouses help organizations transform large quantities of data from
Small versus Big Data

• Big data is not a data store (warehouse or database), nor is it a specific

analytical tool, but rather it refers to a combination of the two. Experts
describe big data as characterized by three Vs (the fourth V—veracity,
or accuracy—is sometimes added).
• These characteristics are present in big but not small data:
• Very large volume of data
• A variety (e.g., images, text, discrete) of types and sources (EHR, wearable
fitness technology, social media, etc.) of data
• The velocity at which the data is accumulated and processed (Glaser, 2014;
Macadamian, n.d.)

64
Health Care Statistics
• Statistical reports can provide managers and executives a
snapshot of their organization’s performance.
• Two categories of statistics directly related to inpatient stays are
routinely captured and reported.

• Census statistics - reveal the number of patients present at any

one time in a facility.

• Discharge statistics. This group of statistics is calculated from

data accumulated when patients are discharged.

• Outpatient facilities and group practices and specialty providers also

routinely collect utilization statistics. Some of the more common
statistics are average patient visits per month (or year) 65
Big Data Examples
• Big data is a practise that is used for a variety of purposes across a
variety of industries and efforts, including health care.

• There is no single big data product, application, or technology, but

big data is expanding the types of data that may be useful in
patient care.

• In the case of Alzheimer's and other chronic diseases such as

diabetes and cancer, for example, online social sites not only
provide a support community for other patients but also contain
knowledge that can be mined for public health research,
medication use monitoring, and other health-related activities.
66
Big Data Analytics
In health care we see an impressive range of analytics:

• Post-market surveillance of medication and device safety

• Comparative effectiveness research (CER)
• Assignment of risk, for example, readmissions
• Novel diagnostic and therapeutic algorithms in areas such as oncology
• Real-time status and process surveillance to determine, for example, abnormal
test follow-up performance and patient compliance with treatment regimes
• Determination of structure including intent, for example, identifying treatment
patterns using a range of structured and unstructured and EHR and non-EHR
data
• Machine correction of data-quality problems

67
HEALTH CARE DATA QUALITY
• In today’s environment, care providers, care coordinators,
analysts, and researchers are all looking to EHRs and electronic
claims records as a source of data beyond the episodic scope.
• Any discussion of health care data analytics and big data include
the EHR as a key data source.
• This expanded use of electronic records and the push for bigger
and better data analytics has raised the bar for ensuring the
quality of the health care data.
• Quality health care data has always been important, but the
criteria for what constitute high-quality data have shifted.

68
HEALTH CARE DATA QUALITY
Operational definitions for quality:

• “conformance to requirements” or “conformance to standards”.

(quality “gurus,” Philip B. Crosby and Joseph M. Juran. Crosby (1979)
• “fitness for use,” products or services must be free of
deficiencies. (Juran & Gryna, 1988)

 the criteria against which quality is measured will change depending on

the product, service, or use. Herein lies the problem with adopting a
single standard for health care data quality - it depends on the use of
the data.

69
HEALTH CARE DATA QUALITY
• Before an organization can measure the quality of the information it
produces and uses, it must establish data standards. And before it can
establish data standards it must identify all endorsed uses of the EHR.

• To effectively use EHR data to create new knowledge, either through

analytics or research, will require HIT leaders to adopt the more
stringent data quality criteria posed by these uses.

• Wells, Nowacki, Chagin, and Kattan (2013) identify missing data as

particularly problematic when using the EHR for research purposes.
They further identify two main sources of missing EHR data:
1. Data were not collected
2. Documentation was not complete
70
FRAMEWORKS for examining HEALTH CARE
DATA QUALITY

1. AHIMA Data Quality Characteristics:

• Data accuracy
• Data accessibility
• Data comprehensiveness
• Data consistency
• Data currency
• Data definition
• Data granularity
• Data precision
• Data relevancy
• Data timeliness

71
FRAMEWORKS for examining HEALTH CARE
DATA QUALITY

2. Weiskopf and Weng Data Quality Dimensions:

• Completeness
• Correctness
• Concordance
• Plausibility
• Currency

72
Strategies for Minimizing Data Quality Issues

• Health care data standardization requires clear, consistent

definitions.
• One essential tool for identifying and ensuring the use of standard
data definitions is to use a data dictionary.
• AHIMA defines a data dictionary as “a descriptive list of names
(also called ‘representations’ or ‘displays’), definitions, and
attributes of data elements to be collected in an information
system or database”
• The Markle Foundation (2006, p. 4) propose that a data quality
program include “automated and human strategies”:
1. Standardizing data entry fields and processes for entering data
2. Instituting real-time quality checking, including the use of validation and
feedback loops
3. Designing data elements to avoid errors
4. Developing and adhering to guidelines for documenting the care that was 73
Strategies for Minimizing Data Quality Issues

• Through the use of electronic data entry, users can be required to

complete certain fields, prompted to add information, or warned
when a value is out of prescribed.
• Data quality is improved when these systems also incorporate
error checking.
• As noted in the Perspective many of the data in existing EHR
systems are recorded in an unstructured format, rather than in
data fields designated to contain specific pieces of information,
which can lead to poor health care data quality. Natural language
processing (NLP) is a promising, evolving technology that will
enable efficient data extraction from the unstructured components
of the EHR, but it is not yet commonplace with health care
74
systems.
Summary: Chapter 2

Health Care Data

• Without health care data and information, there would be no need for health care
information systems.

• Patient record and claims content as sources for health care data

• Use of data analytics and big data

• Two frameworks for examining health care data quality

• Information technology, in general, and the EHR, in particular, can be leveraged to

improve the quality of health care data
75