UM Healthcare Data Management Discussion Replies

Respond to two peers separately 7 to 8 sentences each.

Peer# 1

Part 1: 

Health literacy aids individuals to receive understanding on basic health knowledge and services. This is important because it uses relevant data to make source confirmed decisions. Imagine I were training multiple people on health information and services. If I not only explain in detail, but provide visual aids, that would be an example on health literacy. Another example would be if I were training these people one on one, I would allow them to ask questions and I’d provide detailed responses. 

Preventive controls main endeavor is to achieve the the chance of errors before they aspire. An example of a preventive control is using procedures and tools to detect possible fraud before it happens. Imagine a person stole someones check book, wrote out a check and signed the original owners name. To be proactive, the bank will verify the check before cashing it. 

Detective controls are arrangements for situations that have already materialized. Detective controls provide resources. Incident alerts are examples of detective controls. Imagine you are at work and you receive an email on an incident that happened with instructions on how to avoid that from happening again in the future. 

Corrective controls are put in place when errors are identified. In conclusion, this reduces the risk from occurring. An example would be giving updated procedures and policies to staff members so they acknowledge how to avoid specific risks. 

Part 2:

1. Nomenclatures are a “system of naming things” (Davis,N 2020). They bridge communication for specific codes. For example, ICD-10 code L70.0 translates to Acne Vulgaris when documented. Classification on the other had refers to the organization of these codes, as well as adding a procedural code if necessary. 

2. Taxonomy is important due to its ability to understand when a code set is incorrect. Taxonomy organizes these codes to make them understandable and classify a correct diagnosis. Without these taxonomies, keeping these advanced and important codes in correct structure would be difficult to understand. 

3. Clinical Vocabulary provides more in-depth data entry to avoid misunderstandings during communication. Without this, communication could be misunderstood and potentially harm a patient. For example, a patient is coming in to have her right breast removed due to cancer. If communication is not specific or clear enough, it is possible that the other breast could be removed instead. With clinical vocabulary, these mistakes are easily avoided due to the precise terminology and clarification provided. 

Peer # 2 

What is meant by the term “health literacy”? Why is it important?  Please include examples to demonstrate your practical understanding of what you have learned and how to apply it.

Health literacy is a patient’s ability to access, understand, and implement their plan of medical care, and health issue. Understanding one’s own health, diseases, and preventative care is very important for healthy longevity. An example of health literacy is when a person that has had a heart attack will have an educator come to their hospital room and go over how the patient can log into their MyChart (EHR) to see their own medical information, appointments, medication refill requests, and how to contact their doctor. The educator will also explain what medication the patient will be taking, why, and how. The educator will also go over nutrition, and heart healthy foods. Medical providers want to make sure that the patient has a good understanding of their own health, creating good health literacy.  When a patient is diagnosed with diabetes the same type of educator will call, video chat, or do in-person education with the patient.  The medical center that I work for holds a two hour class once or twice a month on diabetes education that anyone can attend.

The development and implementation of internal controls aid in the protection of data quality and integrity. List and define three fundamental types of internal controls, describe the essential purpose or function of each type, and provide a practical example of each control type.

Preventative controls are in place to make sure that data errors and do not occur.  Preventative controls are designed to be implemented prior to a threat event and reduce and/or avoid the likelihood and potential impact of a successful threat event. Examples of preventative controls include policies, standards, processes, procedures, encryption, firewalls, software validity checks and physical barriers. Preventive controls are in place to keep patient information secure from cyber attacks.

Detective controls are designed to detect a threat event while it is occurring and provide assistance during investigations and audits after the event has occurred. Examples of detective controls include security event log monitoring, host and network intrusion detection of threat events, and antivirus identification of malicious code. A detective control might generate a list of entries that the software recognizes as problematic and send an error report or exception report. If a detective control detects a cyber attack there are preventative measures that usually happen to shut down the database so that no more information is leak.

Corrective controls are designed to mitigate or limit the potential impact of a threat event once it has occurred and recover to normal operations. Examples of corrective controls include automatic removal of malicious code by antivirus software, business continuity and recovery plans, and host and network intrusion prevention of threat events. The process of determining the cause of an errors is often referred to as a root cause analysis (RCA). A corrective control could be software that runs to determine how much information was leaked during the cyber attack, removing any trace of the attack through antivirus software and technology developers, and contacting the patients that had been effected.

Distinguish between nomenclatures and classification.

Nomenclature is a coding system of naming things. Scientific and technical professions typically have their own nomenclatures. Nomenclatures facilitate communication because the users have the specific definition of the codes available (Davis, 2020). Any blood work, images, procedures, doctors’ visits etc. all have an individual code for them that a medical coder will use to bill insurance companies.  For example I needed to get a CBC blood draw, when my doctor puts in the order for the CBC the code appears in the side column of the electronic order form.  This code is then in my file for the visit and a medical biller bills my insurance using that code.

Classification is the systematic organization of elements into categories.  Medical coding classification systems are groups of codes that correspond to individual procedures and diagnoses. They are used to accurately track information about diseases and health conditions in patient records and play a role in the medical billing process. The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics (Davis, 2020). This includes providing a format for reporting causes of death on the death certificate. By assigning specific codes to various medical concepts, classification systems ensure consistency and enable the aggregation and analysis of healthcare data on a large scale. An example is a hospital in France uses the same ICD, or classification system, for Covid as a hospital in the states, this allows the World Health Organization and other international organizations to see the hardest hit areas, where a pandemic or epidemic may be occurring by everyone using the same one umbrella classification. The type of classification system used will depend on what the data are intended to measure. Some datasets may use multiple classification systems.

Why are taxonomies important?

Taxonomy in coding refers to the way a code set is organized. Some code sets are organized by body system, others by type of service (Davis, 2020). When using a code set, its taxonomy or organizational structure is important, not just for the purpose of using or assigning a code, but also to understand when a code is incorrect.  If a patient has a CT of their left arm, the provider does dictation for the left arm, and all the coding on the images is for their left leg, the insurance company will reject paying the bill because the coding doesn’t match.  The code set must match the body part.

What is a clinical vocabulary? 

Clinical vocabulary is the use of, or written, preferred medical terms or their definitions and any alternative terms that may be synonymous. Such as an abrasion is a clinical term that is used across the board for a cut or scrape, or hypertension for high blood pressure.