Running Head: HIM 350
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5-2 Milestone Two: Draft of Interoperability and Data Dictionary
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November 28,2021
SNHU
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Abstract
The purpose of the milestone is to provide an explanation and overview of the
interoperability and data dictionary. The paper sheds light on the classification standards as
well as terminologies essential for successful interoperability and security, technologies
required, legal and ethical standards impacting health information exchange, and steps
involved in the information governance life cycle. The paper also highlights the content that
must be included in the data dictionary, ways to maintain and manage elements in the data
dictionary, the importance of vocabulary standards, and the application of the data dictionary.
II. Interoperability
Standards and Terminologies
There are a number of standards and terminologies that are essential for successful
interoperability and security. The most significant classification standards are the Healthcare
Common Procedure Coding System (HCPCS) and the International Classification of Diseases
(ICD). Centers for Medicare and Medicaid Services (CMS) is responsible for developing the
Healthcare Common Procedure Coding System (HCPCS). HCPCS refers to the collection of
standardized codes representing medical procedures, products, supplies, and services
(American Medical Association, 2001). The codes allow appropriate health insurance claim
processing by different insurers like Medicare. International Classification of Diseases (ICD)
has been developed by the World Health Organization (WHO) (Health Information and
Quality Authority, 2013). It is an international coding system of signs, symptoms, diseases,
social circumstances, and causes of diseases, death, or injuries. It allows effective retrieval
and storage of diagnostic information for clinical use and health management.
The essential terminologies that are vital for successful interoperability and security are the
Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Dental Terminology
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(CDT), Current Procedural Terminology (CPT), National Drug Codes (NDC), and
International Classification of Primary Care (ICPC).
Technologies
There are various technologies that are needed for successful interoperability and
security. One of the prominent technologies is the Master Patient Index (MPI). MPI plays a
vital role in enabling healthcare organizations to gain an understanding of their patient
population and evaluate its own performance (Lintz, 2018). It helps in easy identification of
the patients treated by the healthcare facilities. Another significant technology is the Record
Locator Service (RLS). The RLS offers authorized users about the location of the different
patient health information across various clinical data sources (Milton et al., 2021).
Legal and Ethical Standards
The legal and ethical standards impacting health information exchange are HITECH
and HIPPA. The core aim of the Health Information Technology for Economic and Clinical
Health (HITECH) Act is to accelerate the adoption as well as to promote the meaningful use
of EHRs or electronic health records (Mennemeyer et al., 2016). The Health Insurance
Portability and Accountability Act (HIPPA) of 1996 lays out the national standards for
protecting the medical records of individuals and vital personal health information (The
HIPAA Privacy Rule. HHS.gov, 2021). It sets out the various requirements for disclosure
and use of patient health information. Obtaining the consent of the patient is also a regulation
that impacts health information exchange.
Compliance Measures
In order to ensure optimum protection of patient information, a number of measures
can be taken. One of the measures is to use firewalls. Firewalls can help in monitoring the
incoming as well as outgoing network traffic and block particular traffic on the basis of set
security rules. Another measure is the use of cryptography. The information of patients needs
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to be encrypted. This will ensure that the information can be accessed by authorized medical
users only (Kruse et al., 2017).
Information governance life cycle
Information governance lifecycle refers to the process of effectively managing
information in an organization. The first step in the cycle is the identification of information
that the healthcare organization already has (Information governance lifecycle. BSI, 2021).
The second step is the analysis as well as classification of the information. The third step is
the management of information. The fourth and final step is monitoring progress and
identifying the need for potential improvements.
III. Data Dictionary
Content of Data Dictionary
The important content of the data dictionary includes patient identifiers, admitting
diagnoses, principal and secondary diagnoses, allergies, length of stay, and other vitals.
Patient identifier examples are the name of the patient, gender, and date of birth. It helps in
storing the correct information of patients. The diagnoses refer to the illness or diseases for
which the patient is receiving treatment. Examples of allergies are allergic to certain
medications. Other vital information examples are heart rate, blood pressure, and more.
Management and Maintenance of Data Dictionary Elements
In order to maintain as well as manage the vital elements of the data dictionary, it is
important to develop it with the approval of the key stakeholders by making use of the
nationally recognized standards. ICC and ISO guidelines must also be taken into
consideration for registering metadata. The main rationale behind this is to ensure
interoperability between systems.
Importance of Vocabulary Standards
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It is essential to adopt as well as use vocabulary standards in the HIE. Vocabulary
standards provide the language for capturing primary health data that is vital for meaningful
use. It ensures uniformity of the data language and allows better readability across different
platforms.
Application of Data Dictionary
The use of a data dictionary ensures the standardization of patient data and health
information throughout the system. It ensures that data from other healthcare facilities can be
read as well as interpreted in the same manner throughout the organizations with the use of
HIE.
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References
American Medical Association. (2001). Hcpcs 2002: Healthcare Common Procedure Coding
System: Medicare's National Level II Codes. American Medical Association Press.
Health Information and Quality Authority. (2013). Overview of healthcare interoperability
standards.
Information governance lifecycle. BSI. (2021). Retrieved November 24, 2021, from
https://www.bsigroup.com/en-IE/our-services/cybersecurity-information-
resilience/Services/Information-Governance-Lifecycle/.
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for the
electronic health records. Journal of medical systems, 41(8), 1-9.
Lintz, J. (2018). A Qualitative Study of Master Patient Index (MPI) Record Challenges from
Health Information Management Professionals' Perspectives. Perspectives in Health
Information Management.
Milton, A. C., Hambleton, A., Dowling, M., Roberts, A. E., Davenport, T., & Hickie, I.
(2021). Technology-Enabled Reform in a Nontraditional Mental Health Service for
Eating Disorders: Participatory Design Study. Journal of Medical Internet Research,
23(2), e19532.
Mennemeyer, S. T., Menachemi, N., Rahurkar, S., & Ford, E. W. (2016). Impact of the
HITECH act on physicians’ adoption of electronic health records. Journal of the
American Medical Informatics Association, 23(2), 375-379.
The HIPAA Privacy Rule. HHS.gov. (2021, July 13). Retrieved November 24, 2021, from
https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.
