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

2. 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

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

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

5. 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.”

6. Purpose
To standardize definitions
To ensure consistency

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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

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

21. 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

22. 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

23. 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

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

25. 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

26. Sample Data Dictionary
Data Type
Text
Date
Coded Values

27. Sample Data Dictionary
Format
Alphanumeric
Numeric
DD_MM_YYYY

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