Databases

Data are collected from each patient's chart at the time of discharge from hospital and are recorded on an abstract provided by Canadian Institute for Health Information (CIHI). The abstract collects information on the patient and the nature of their stay. One abstract is completed for each separation (stillbirth, death, discharge) from the hospital.

Hospital is required to submit abstracts as part of the global operating budget funding process, which is covered by funding transfers from the provinces and the territorial Departments of Health. At the hospital data used in many ways. These include the monitoring of of hospital utilization practices, for analysis of health conditions, tracking patient outcomes, research purposes, performance monitoring.

The target population of the Hospital DAD includes inpatient hospital discharges (acute care) and surgical day care discharges. The data are reported for completed cases only. Hospitals do not report on cases that are still being treated.

• Demographic (e.g. postal code, date of birth, etc.),
• Non-medical administrative
  (e.g.health care number, date of admission, etc.),
• Clinical (e.g. diagnosis, procedure, etc.)
• Value added derived data elements such as Case-Mix Group (CMG), Resource Intensity Weight (RIW)
• Additional elements collected at BCW.

Classifications systems in health care provide a standard mechanism for the capture and coding of diagnoses and interventions. ICD-10-CA is the enhanced Canadian version of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems and replaced the ICD-9-CM in 2001/2002 FY, which earlier in 1997/1998 replaced ICD-9 classifications. CCI is the Canadian Classification of Health Interventions, developed and maintained by CIHI. It contains a comprehensive list of diagnostic, therapeutic, and support interventions, and replaced ICD-9_CM intervention codes in 2001/2002 FY which replaced CCP in 1997/1998 FY.

At BCW DAD data available for almost 10 years from April 2001 up to date. Archived data from 1985 to 2000 also available with some limitations, especially for earlier years 1985-1991.

For more information, contact vnevmerjitskaia@cw.bc.ca

BCW hospital is a participant of comprehensive province-wide perinatal database collected for the purpose of evaluating perinatal outcomes, care processes and resources, ultimately improving maternal, fetal, and newborn care.

PDR database is standardized set of comprehensive data elements necessary for the surveillance and optimization of Neonatal, Maternal and Fetal health that could be used to establish and monitor the quality of perinatal services encompassing the entire perinatal event, starting from the initial antenatal care to birth registration and initial post delivery follow-up.

The registry collects, summarizes, interprets and reports on perinatal events, outcomes and care processes at a hospital, regional and provincial level.

• Maternal care: Demographic and Non-clinical information; medical/obstetrical history; pregnancy; labour and delivery; postpartum care.
• Baby care: Demographic and Non-clinical information; Newborn birth event; Newborn Care; Transferred baby care

Requesters should be prepared to describe the variables required, the type of data file needed, other pertinent details of the project ( e.g. data linkage needs).
List of data elements

The submission and approval process, turnaround time for completion, costs for data depends on the type of data request For more information, contact vnevmerjitskaia@cw.bc.ca

ADT is a core integrated patient management system that collects the initial set of data that is used to establish a "record" of a new visit in all affected hospital departments.

The purpose of the database is to run the entire patient care workflow, from the registration of patient information in the Patient Master Index (PMI) to bed tracking and discharge.

Data collected on each transaction (also called patient activity) initiated from nurse ward such as change of patient location, service, encounter type, etc) and house most patient demographic information, payment information, and visit information including attending physician, admit date and time, discharge date and time, service location, patient visit type.

Data from Cerner and former ADT (Affinity and Encompass systems) are organized into Integrated Data sets: Patient encounter (one record per patient visit), Patient activity (records every movement of the patient while in the hospital), Census( count of patients at particular time).

For more information, contact vnevmerjitskaia@cw.bc.ca

Aggregated or summarized financial and statistical administrative based on Standards for Management Information Systems in Canadian Health Service Organizations (MIS Standards). Visit CIHI website to learn more on MIS Standards.

Data collected on day to day Hospital services operations. All reports based on the MIS Standards and related to staffing, costs, workload and provision of services.

• accountability reporting by managers for resource use,
• development of budgets based on meaningful workload and activity projections,
• more precise resource allocation, and
• more informed management decisions.

The primary users of this information are the health service organization's front-line managers and senior management team. The organization's board of directors also uses MIS information to assist them in effectively discharging their responsibilities.

Secondary users of MIS data include provincial/territorial Ministries of Health, Statistics Canada and researchers.

Data available form 2001.

For more information, contact vnevmerjitskaia@cw.bc.ca

• Better efficiency of operating room utilization,
• Reduction of cost of materials;
• Better staff management;
• Decrease patient delays;
• Enhanced satisfaction among patients, staff, and physicians

Using ORSOS®, information is entered as events occur, so that data collection is accurate, thorough and timely. ORSOS® provides extensive, on-demand reporting capabilities.

• OR booking date/time;
• Date and time procedure starts and ends,
• Date and time Patient enters and exit OR,
• Date and time Patient transferred to PACU,
• Primary procedure done;
• Primary Surgeon Information

For more information, contact vnevmerjitskaia@cw.bc.ca

• provide evaluation of fetal anomalies identified on prenatal ultrasound;
• identify referral patterns to the program;
• allow comparison of prenatal findings to pregnancy outcome;
• Help assist in overall quality assurance of the service.

Data collected on a retrospective basis and focused on:

• Referral information to FDTS that includes
  • maternal demographic information;
  • referral criteria;
  • maternal medical and obstetrical histories;
  • prenatal procedures,
• Results of Investigation
  • fetal testing results (DNA, Triple Screen, blood work)
• Outcome of Pregnancy
  • outcome information;
  • newborn diagnosis.

Outcome data collected 5 -6 months after.
Referrals to this service are about 450 cases per fiscal year.
Data collection started in 1997.
All data requests should be forwarded to Dr. Lim for review.

For more information, contact vnevmerjitskaia@cw.bc.ca

Standardized data set of information that summarizes the characteristics, care process and outcome of pregnancy for mothers presenting for amniocentesis in the province of British Columbia to ensure co-ordination of amniocentesis databases and to provide standardized reporting/feedback to each regional centre.

The database population includes Advanced Maternal Age (AMA) and positive triple screen amniocentesis patients and currently being collected for: BC Women's, Surrey Memorial Hospital, Nanaimo Regional Hospital.

There are approximately 2800 visits per year. Data available from 2002.

• Demographic data;
• Indication for Amniocentesis;
• Genetic Counseling referral;
• Past Obstetrical History;
• Current pregnancy data;
• Obstetrical Risks;
• GA from dating U/S;
• Blood group and type;
• Ultrasound data;
• Procedural data;
• Post-procedural complications;
• Post procedural follow up-results

Original data source :Provincial Amniocentesis forms and/or patient chart (Amnio visit)

• Dr. Lim - BC Women's Hospital
• Dr. Mathews - Nanaimo General Hospital
• Dr. Still - Surrey Memorial Hospital
• Dr. Farquharson - Royal Columbian Hospital
• Dr. Tsang - Prince George Regional Hospital
• Victoria - new site to start soon, contact to be determined
• Data request form completed and reviewed at TEAM (Diagnostic/Ambulatory Program)

For more information, contact vnevmerjitskaia@cw.bc.ca

Specialized genetics services are delivered by a team consisting of Medical genetics physicians from the U.B.C. Department of Medical Genetics, Genetic Counselors (GC), and support staff.

Clinical genetic services include the assessment and diagnosis of birth defects and genetic diseases, and the provision of genetic counseling. Pregnant women may also be referred for assessment, counseling, and/or prenatal diagnosis.

Data is collected in stand alone MS Access97 database and consists of clinical and administrative information for each referral visit:

• Patient demographics;
• Referral information;
• Obstetrical history and gestational age on Ultrasound on prenatal intakes;
• Information on family members;
• Attending doctors;
• Patient concerns;
• Diagnoses (entered after genetic counselor assessed the case).

To capture Concerns and Diagnoses the OMIM (Online Mendelian Inheritance in Man) classification system is used.

Other uses of database: to keep track on chart location and for cross-reference of family members.

Data collection started in 1947 with 2-3 records per year and expanded substantially after 1980.

Data available by request through program staff only.

Data quality concerns:

• To capture Patient concerns and diagnoses the OMIM (Online Mendelian Inheritance in Man) classification system is used. Data is entered by a health record administrator in a free text field using manually maintained list of Genetic Disorders stored in a folder as a reference. The problem here: the same diagnoses could be entered in many different ways and it is hard to search and summarize.
• Several fields collects data as a free text (blood type, visit type).
• Some fields contain different information collected during different point of times.
• Some fields are discontinued in 1998-1999.
• Changes do data collection was not documented.

For more information, contact vnevmerjitskaia@cw.bc.ca

ALI Ultrasound Reporting Package is a structured report with searchable fields.

Purpose of this package is to collect results of the Ultrasound Procedure and print/view a report.

The definitions of the fields are based on practices and established standards.

Data collected per individual patient for each ultrasound test via computerized forms. There are several forms (in .pdf) that are filled, but not every sonographer gets all forms filled and not all data points get filled either.

Sonographer records:

• fetuses measurements,
• fetuses biometry,
• Calculated GA,
• Maternal findings, and workload.

Texts in Impression, Summary, patient history and other fields are free texts but selected form prerecorded ALI impression tree. Currently there are approximately 50000 records since 2004.

For more information, contact vnevmerjitskaia@cw.bc.ca

The Neonatal Network (CNN) was founded in 1995 by Shoo Lee, MBBS, FRCPC, PhD and now includes members from 29 hospitals and 17 universities across Canada. Learn more about Canadian Neonatal Network go to CNN website.

BCW is contributing to standardized neonatal intensive care unit (NICU) database and provides a unique opportunity for researchers to participate in collaborative projects on a national and international scale.

The main purpose of this database is to provide the infrastructure to facilitate multi-disciplinary, collaborative research dedicated to the improvement of neonatal-prenatal health and health care in Canada and internationally.

Data collection consists of four major categories of information.

1. Registration Information: Background information such as birth weight, gender, gestational age and obstetric variable will be recorded on admission to the NICU.
2. Illness Severity: Illness severity will be recorded using SNAP, a physiology based measure.
3. Transport Information: Transport details and physiological details as a result of transport situations will be recorded after 12 hours of admission.
4. Discharge Abstract: At discharge, abstractors will record a number of outcome variables including diagnoses, complications, survival, discharge date and disposition.

Abstractors are responsible for abstracting every eligible admission to the NICU. Eligible babies are babies who stay in the NICU for at least 24 hours OR who die/are transferred to another level 2 or 3 facility within 24 hours.

All data collection conducted by medical chart review. Data collection occurred at the bedside to maximize the amount of information obtainable.

Neonatal Network consists of

• Core Database: The Network will maintain a core Network database. Institutional representatives and the Steering Committee decide policy concerning content and use of the database.
• Project Database: Research projects may request utilization of the Network data acquisition system to collect project related data. Such requests will be approved by the Steering Committee. Access to such data will be limited to members of the research project. Expenses relating to such data acquisition will be the responsibility of the project researchers concerned

All request for BCW NICU should be directed to Anne Synnes, neonatologist. Department of neonatology, BCW.

For more information, contact vnevmerjitskaia@cw.bc.ca

The Sexual Assault Service (SAS) works in partnership with Vancouver Hospital and Health Sciences Centre to provide sensitive and comprehensive emergency medical care to sexual assault survivors.

Services to survivors include assessment and treatment of injuries, STD prophylactic treatment, pregnancy prevention, forensic evidence collection, counseling follow-up and referrals to medical, legal and counseling services.

Data collected is used for planning and development of program, for quality of care evaluation, for MSP billing, and for research purposes.

Data collection consists of five categories:

• Demographic and Admission data;
• Assault information: details obtained from a patient;
• Screening (for drugs, forensic samples)/treatment info;
• Follow up information.

Patients seen by SAS : female, male and transgender patients presenting with a history of sexual assault if the patient is 13 years of age or old, able to give informed consent, has no urgent medical concerns, assault occurred within the last 7 days.

Record is sent to SAS program after patient discharged from VGH Emergency and entered by administrative clerk into Access Database. There are approximately 230 records per year. Each visit is recorded separately.

Database started since 1997, But data elements collected had been modified several times over the years. Die to sensitivity of information, data available by request through program staff only.

SAS research reflects commitment to evaluating and improving sexual assault services, and the promotion of awareness regarding issues related to sexual assault.

For more information, contact vnevmerjitskaia@cw.bc.ca

Proton manages records of a newborn's demographic data, histories, synopses, problems, narratives, investigations, medications, diagnoses, treatment plans, and vital stats.

Record level is based on daily activities. Data stored as text, binary numbers, dates, times and as items encoded to clinical standards (ICD codes).

Proton plays major role on how NICU operates, manages its data, and delivers patient care. Data entered manually each day. There are approximately 700 admissions annually. System was implemented in 1993 and house an archival data uploaded from the previous system (around 20 years worth of data).

Only authorized users can access Proton. Data available by request through program staff only. All requests should be forwarded to Claydon, Jennifer, Program Manager, Division of Neonatology & Neonatal Program; 604-875-2002, jclaydon@cw.bc.ca

Prenatal Biochemistry Laboratory contains specific clinical and laboratory information required for generating maternal prenatal screen reports. Original data source: Healthcare provider requesting the prenatal screen.

Purpose of data collection: To issue patient-specific maternal prenatal screen reports to their individual healthcare provider(s).

Types of data collected:

• Laboratory results for prenatal serum screening tests,
• nuchal translucency,
• clinical information that affects interpretation of results.

Healthcare provider receives individual patient reports.

Provincial Prenatal Genetic Screening Program and Prenatal Biochemistry Laboratory monitor results at regular intervals for trends in laboratory assays and screening performance.

Reporting system implemented in February 2009 and it has all data from then to date.

For data requests contact Director of Prenatal Biochemistry Laboratory and/or Provincial Prenatal Genetic Screening Program Dr. Halstead for requests regarding usefulness of this database, costing or other information. All requests must be Approved by Institutional and UBC research ethics approval committee.

Note that the Alpha software is exceptionally limited in its search capability: prior consultation advised.