Fundamentals of Health Information – Week 5 Robyn Korn, MBA, RHIA, CPHQ

General Information Discussion Board Assignments Enter first post by Saturday and a total of 3 posts by Tuesday. Assignments Make sure your name is on the assignment attachments when they are submitted

General Information Late work will not be accepted unless there are clear and compelling extenuating circumstances.

Data Dictionary No data dictionary = Garbage in – garbage out Foundation of an information system Central building block supporting communication across business processes

Definition AHIMA work group defines a data dictionary “…as a descriptive list of names (also called representations or displays), definitions, and attributes of data elements to be collected in an information system or database.”

Purpose To standardize definitions To ensure consistency

Potential Problems Same element by different names St. Louis Saint Louis St Louis Different elements by same name Pt – patient PT – physical therapy pt – prothrombin time

Developing a Data Dictionary Design a plan for the development, implementation, and continuing maintenance of the data dictionary. Collaborative process Media choice (paper, electronic, spreadsheet, relational databases) Funding and staffing Licensing agreements Continuing education of staff

Developing a Data Dictionary Develop an enterprise data dictionary that integrates common data elements used across and enterprise. Name of the element Locator key Ownership Entity relationships Date first entered in system Date terminated from system System of origin

Developing a Data Dictionary Ensure collaborative involvement and buy-in of all key stakeholders when data requirements are being defined for an information system. Departments HIM IS Clinical Financial Administrative Support Facilities Satellites Corporate External entities

Developing a Data Dictionary Develop an approvals process and documentation trail for all initial data dictionary decisions and for ongoing updates and maintenance. Activations Deactivations Relevant dates Events Decisions Maintenance Change Control

Developing a Data Dictionary Identify and retain details of data versions across all applications and databases. Data reliability – version control Additions Deletions Effective dates

Developing a Data Dictionary Design flexibility and growth capabilities into the data dictionary so that it will accommodate architecture changes resulting from clinical or technical advances or regulatory changes. Accommodate a dynamic system Concept permance

Developing a Data Dictionary Design room for expansion of field values over time. Mapping and transferring guidelines clarified Example: race or ethnicity (4 or 6 elements) Example: gender (M, F, unknown or other) Example: ICD-9-CM to ICD-10-CM

Developing a Data Dictionary Follow established ISO/International Electrotechnical Commission (IEC) 11179 guidelines or rules for metadata registry (data dictionary) construction to promote interoperability and automated data sharing. Uniformity to prevent industry fragmentation

Developing a Data Dictionary Adopt nationally recognized standards and normalize field definitions across data sets to accommodate multiple end user needs. Data characteristics Terminologies Common integrated data and terminology model

Developing a Data Dictionary Beware of differing standards for the same clinical or business concepts. Wound Staging Pain scales

Developing a Data Dictionary Use geographic codes and geocoding standards that conform to those established by the National Spatial Data Infrastructure and the Federal Geographic Data Committee, following the guidelines of the Federal Information Processing Standards. Street addresses Zip codes County State Country

Developing a Data Dictionary Test the information system to demonstrate conformance to standards as defined in the data dictionary. Test sample data input and output for Conformance Validity reliability

Developing a Data Dictionary Provide ongoing education and training for all staff. New employee orientation Ongoing education

Developing a Data Dictionary Assess the extent to which the use of the agreed-upon data elements supply consistency of information sharing and avoid duplication. Updates due to changes in clinical practices

Typical Contents Table Name Attribute(s) or field name(s) Attribute description(s) Attribute data type (text, number, date, etc.) Attribute format Range of values Whether an attribute is required Relationships among attributes

Sample Data Dictionary Data Element Medication Name Dosage Quantity number Quantity form Frequency Start Date Stop Date Prescribed by Prescription Date Prescription Number Pharmacy Allergic Reaction Sources of medication list

Sample Data Dictionary Variables (Attributes) Caplets, capsules, oral TID, BID, QID Local pharmacy data Patient Primary Care Physician

Sample Data Dictionary Description Name of the medication (name brand or generic Medication dosage prescribed Number or volume of medication dispensed Form in which the medication was dispensed Frequency of medication administration Medication start date Medication stop date Name and credentials of provider who prescribed the medication Date medication prescribed Unique identification number assigned to the prescription Name of pharmacy where prescription was filled Description of allergic reaction Source(s) from which the patient’s medication list was collated

Sample Data Dictionary Data Type Text Date Coded Values

Sample Data Dictionary Format Alphanumeric Numeric DD_MM_YYYY

References AHIMA Practice Brief – Guidelines for Developing a Data Dictionary AHIMA Practice Brief – Data Content for EHR Documentation