Question

Minimum Data Sets for Personal Healthcare Records Part 1

Medical facilities have implemented the use of Electronic Healthcare Records (EHRs) for a variety of reasons. Some facilities implemented their use for financial reasons while other facilities implemented their use to better serve their patient population. No matter the reason for their implementation, EHRs can be an asset to any medical facility.

One problem with EHRs is that there is no standardized set of data that each EHR collects, commonly referred to as a minimum data set. Large EHR systems, such as EPIC, have multiple modules that collect and share data. Smaller EHR systems don’t collect as much data so the systems may not mesh as well as one would want. Additionally, the market includes Personal Healthcare Record systems that are geared toward individual use.

Your task is to identify the Minimum Data Set (MDS) of personal data you think should be included in every Personal Healthcare Record. Organize the data elements into discreet sets with labels and a sentence of general descriptions. Examples of discreet data sets would be Lab Tests or Immunizations.

Textbook - Health Care Information Systems: A Practical Approach for Health Care Management 4th Edition (Wagner, Lee and Glaser)

Chapter 3 - Health Care Information Systems

Answer 1

*Minimum data set is a federally mandated standard assessment form that Medicare- and/or Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents
•Consists of a core set of screening and assessment elements based on common definitions
•To meet federal requirements, long-term care facilities must complete an MDS for every resident at the time of admission and at designated reassessment points throughout the resident's stay.

*The data collected via the MDS are used to develop care plans for residents and to document placement at the appropriate level of care.

•The MDS organizes data according to 20 main categories

•Each category includes a structured list of choices and responses
•The use of structured lists automatically standardizes the data that are collected

*The major categories of data collected in the MDS include:

1. Demographic information
2. Identification and background information
3. Cognitive patterns
4. Communication/hearing patterns
5. Vision patterns
6. Mood and behavior patterns
7. Psychosocial well-being
8. Physical functioning and structural problems
9. Continence in the past 14 days
10. Disease diagnoses
11. Health conditions
12. Oral/nutritional status
13. Oral/dental status
14. Skin condition
15. Activity pursuit patterns
16. Medications
17. Special treatments and procedures
18. Discharge potential and overall status
19. Assessment information
20. Therapy supplement for Medicare PPS

*Data collected by the MDS is used for:

•The data collected by the MDS are used to develop a resident assessment protocol (RAP) summary for each resident
•The MDS provides a structured way to organize resident information and develop a resident care plan
•Problems identified through the assessment process are documented and a RAP is triggered

*For each triggered resident assessment protocol (RAP), the facility must describe the following factors:

•Nature of the condition (may include the presence or lack of objective data and subjective complaints)
•Complications and risk factors that affect the decision to proceed to care planning
•Factors that must be considered in developing individualized care plan interventions
•Need for referrals/further evaluation by appropriate healthcare professionals

*Because the MDS is used nationwide to collect data about residents in long-term care facilities:

•The data can and will be used as a basis for identifying and assessing resident safety and quality improvement activities in nursing homes
•For example, MDS data can give valuable information about the incidence of falls and their impact on the care of nursing home residents
•From those data, prevention measures can be developed and implemented to address a common and significant problem in elderly care

*CPOE(Computerized provider order entry) system at its most basic level is a computer application that accepts provider orders electronically, replacing handwritten or verbal orders and prescriptions.

*Most CPOE systems provide physician and other providers with decision-support capabilities at the point of ordering.

*For example, an order for a laboratory test might trigger an alert to the provider that the test has already been ordered and the results are pending

*An order for a drug to which the patient is allergic might trigger an alert warning to the provider of an alternative drug.

*Reminders must also show that the patient is due for health maintenance test such as mammography or a cholesterol test or for an influenza vaccine