Medical Data Management

Medical Data Management is a systematic introductionto 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 undergraduateand 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 hospital information 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 chapters feature 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 which aims to clarify the unclear and sometimes inconsistent terminology surrounding the topic.

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

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

What is included with this book?

The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.

The Used, Rental and eBook copies of this book are not guaranteed to include any supplemental materials. Typically, only the book itself is included. This is true even if the title states it includes any access cards, study guides, lab manuals, CDs, etc.