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What's behind the Data: An Examination of the Processes and Policies Underlying the Routine Collection of Clinical Data in Ontario

Author: PAULA BLACKSTEIN-HIRSCH, RUTH CROXFORD, VIRGINIA FLINTOFT, and ADALSTEINN D. BROWN
Published in JHHSA, Vol. 29 No. 1

This article surveyed the processes and policies underlying the
routine collection of clinical data in acute care hospitals in Ontario,
Canada. Although there is evidence of a small shortfall in the
availability of human resources, most health records departments
employ experienced staff with health records certification. However,
there is much more important variation in the documented and
undocumented processes used to generate routinely collected clinical
data. Current guidelines and coding schedules are helpful but
insufficient to guide the production of good quality data. The variations
in the processes used to produce clinical data have important
implications for the management, reimbursement, and planning of
healthcare. This is particularly critical at a time when hospitals and
other stakeholders, such as governments, are relying more and more on
accurate, reliable, and comparable data.

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