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). aa 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.
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The essential terminologies that are vital for successful interoperability and security are
the Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Dental
Terminology (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
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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. 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
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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
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.
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The HIPAA Privacy Rule. HHS.gov. (2021, July 13). Retrieved November 24, 2021,
from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.
