Medical Data Management : A Practical Guide

by Leiner, Florian

• ISBN13: 9780387951591
• ISBN10: 0387951598
• Edition: 1st
• Format: Paperback
• Copyright: 2003-01-01
• Publisher: SPRINGER

Summary

Medical Data Management is a systematic introduction to the basic methodology of professional clinical data management. It emphasizes generic methods of medical documentation applicable to such diverse tasks as the electronic patient record, maintaining a clinical trials database, and building a tumor registry. This book is for all students in medical informatics and health information management, and it is ideal for both the undergraduate and the graduate levels. The book also guides professionals in the design and use of clinical information systems in various health care settings. It is an invaluable resource for all health care professionals involved in designing, assessing, adapting, or using clinical data management systems in hospitals, outpatient clinics, study centers, health plans, etc.The book combines a consistent theoretical foundation of medical documentation methods outlining their practical applicability in real clinical data management systems. Two new chapters detail hospitalinformation systems and clinical trials. There is a focus on the international classification of diseases(ICD-9 and -10) systems, as well as a discussion on the difference between the two codes. All chaptersfeature exercises, bullet points, and a summary to provide the reader with essential points to remember.New to the Third Edition is a comprehensive section comprised of a combined Thesaurus and Glossary whichaims to clarify the unclear and sometimes inconsistent terminology surrounding the topic.

Author Biography

Florian Leiner, Munich, Germany Wilhelm Gaus, University of Ulm, Germany Reinhold Haux, University for Health Informatics and Technology, Tyrol, Innsbruck, Austria Petra Knaup-Gregori, University of Heidelberg, Germany

Table of Contents

Foreword to the First German Edition	vii
Series Preface	ix
Preface	xi
What Is Medical Documentation About?	1	(10)
What It Is and What It Isn't	1	(1)
Medical Documentation: Do We Really Need It?	2	(1)
Problems and Motivation	2	(1)
More Important Today Than Ever Before	3	(1)
What Are the Objectives of Medical Documentation?	3	(3)
General Objectives	3	(1)
Objectives in Patient Care	4	(1)
Objectives in Administration	4	(1)
Objectives in Quality Management and Education	5	(1)
Objectives in Clinical Research	5	(1)
Multiple Use of Patient Data	6	(1)
Medical Documentation: Child's Play?	7	(1)
Computer-Supported Medical Documentation: A Panacea?	8	(1)
Checklist: Objectives of Medical Documentation	8	(1)
Exercises	9	(2)
Basic Concepts of Clinical Data Management and Coding Systems	11	(32)
The Documenting Institution	11	(4)
The Physician's Office and the Outpatient Clinic	11	(1)
The Hospital	12	(1)
Other Relevant Institutions	13	(2)
From Attributes to Data Management	15	(8)
Objects and Attributes	15	(2)
Definitions, Labels, and Terminology	17	(2)
Data, Information, and Knowledge	19	(2)
Documents	21	(1)
Data Management Systems	21	(1)
Exercises	22	(1)
Clinical Data Management Systems	23	(7)
Characteristics of Clinical Data Management Systems	23	(7)
Exercises	30	(1)
Medical Coding Systems	30	(13)
Coding Systems: Why Do We Need Them?	31	(1)
What Is a Coding System?	32	(1)
Classifications and Nomenclatures	32	(9)
A Few Additional Remarks	41	(1)
Exercises	41	(2)
Important Medical Coding Systems	43	(20)
International Classification of Diseases (ICD)	43	(4)
The 10th Revision (ICD-10)	44	(2)
Extensions to the ICD	46	(1)
Procedure Classifications	47	(5)
International Classification of Procedures in Medicine (ICPM)	47	(2)
ICD-10-Procedure Coding System (ICD-10-PCS)	49	(3)
Systematized Nomenclature of Medicine (SNOMED)	52	(5)
SNOMED Reference Terminology (SNOMED RT)	53	(3)
SNOMED Clinical Terminology (SNOMED CT)	56	(1)
The TNM Classification of Malignant Tumors	57	(3)
Structure	58	(2)
MeSH and UMLS	60	(1)
Exercises	60	(3)
Typical Medical Documentation	63	(12)
The Patient Record	63	(2)
Patient Record Archives	65	(1)
Clinical Basic Data Set Documentation	66	(1)
Clinical Findings Documentation	67	(1)
Clinical Tumor Documentation	68	(1)
Documentation for Quality Management	69	(2)
Clinical and Epidemiological Registers	71	(1)
Documentation in Clinical Studies	72	(1)
Documentation in Hospital Information Systems	73	(1)
Exercises	73	(2)
Utilization of Clinical Data Management Systems	75	(14)
Patient-Oriented Analysis	75	(3)
Patient-Group Reporting	78	(4)
Clinical Studies	82	(4)
Quality Measures in Information Retrieval	86	(1)
Exercises	87	(2)
Clinical Data Management: Let's Make a Plan!	89	(14)
Planning Medical Coding Systems	89	(3)
General Principles	89	(1)
Principles of Ordering Qualitative Data	90	(1)
Principles of Ordering Quantitative Data	91	(1)
Planning Clinical Data Management Systems	92	(3)
Why Plan Them at All?	92	(1)
The Documentation Protocol	93	(1)
Prolective and Prospective Analyses	94	(1)
Additional Remarks	94	(1)
Example: A Tumor Documentation Protocol	95	(7)
Exercises	102	(1)
Documentation in Hospital Information Systems	103	(14)
The Hospital Information System	103	(7)
The Concept	103	(1)
The Significance	104	(1)
The Need for a Strategic Plan	105	(2)
Important Hospital Functions	107	(3)
Exercises	110	(1)
Management and Operation of Hospital Information Systems	110	(2)
The Strategic Plan	112	(1)
The Electronic Patient Record	112	(4)
What Is an Electronic Patient Record?	113	(1)
Advantages and Disadvantages of the Electronic Patient Record	114	(1)
Introducing the Electronic Patient Record	115	(1)
Methodology of Medical Documentation	116	(1)
Data Management in Clinical Studies	117	(12)
Therapeutic Trials	118	(1)
Good Clinical Practice (GCP)	119	(1)
Study Protocol	120	(1)
Case Report Forms (CRFs)	120	(1)
Monitoring	121	(1)
Auditing and Quality Assurance	122	(1)
Processing of the Primary Data	123	(2)
Checking and Correcting Data	123	(1)
Classification of Nonstandardized Entries	123	(1)
Secondary Data Acquisition	124	(1)
Database Closure	124	(1)
Analysis	125	(1)
Archiving the Trial Master File	125	(1)
Checklist: Data Management in Clinical Studies	126	(1)
Exercise	127	(2)
Concluding Remarks	129	(2)
Suggested Further Information	131	(6)
General References	131	(1)
Standardization Bodies	131	(1)
Education in Medical Documentation	132	(1)
Professional and Other Relevant Organizations	133	(1)
Information on Coding Systems	133	(1)
Basic Literature on Medical Documentation	134	(3)
Thesaurus of Medical Documentation	137	(60)
Documentation Protocol of the Thesaurus	137	(2)
Thesaurus Entries	139	(58)
Index	197