Running Head: HIM 350
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5-2 Milestone Two: Draft of Interoperability and Data Dictionary
HIM 350
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). f 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 to be encrypted.
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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.
References
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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.
