HIM 350 Milestone Two

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May 24, 2024

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Interoperability and Data Dictionary Dori F. Lewis Southern New Hampshire University Communication and Technologies Him 350 Professor Anna Erickson April 7, 2024

Interoperability Standards and Terminologies: Interoperability allows for information exchange between various applications and systems, allowing for smoother, coordinated care. Proper health information must be exchanged. Standards like the International Classification of Diseases (ICD) and the Healthcare Common Procedure Coding System (HCPCS) are required to do this successfully. The Center for Medicare and Medicaid Services (CMS) established the HCPCS to reimburse supplies and services provided in an ambulatory or outpatient setting. There are two levels to the HCPCS, level one being five-digit numeric codes and level two comprising five-digit alphanumeric codes. Terminologies comprise of Systematized Nomenclature of Medicine Clinical Terminology (SNOMED-CT). SNOMED-CT is the standard for sharing disease descriptions and clinical knowledge among healthcare workers. There are other terminologies, such as Current Dental Terminology (CDT), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology, International Classification of Primary Care (ICPC), and National Drug Codes (NCD) are necessary for successful interoperability. Technologies The Record Locator Service enables the user to find patient records and information wherever care was received. The Enterprise Master Patient Index (EMPI) is a permanent database containing patient-identifying information, health record numbers, and other pertinent data for every treatment or visit, including admissions. Records should be redundant and more accurate. Legal and Ethical Standards

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and the Health Information Technology for Economic and Clinical Health (HITECH) Act Omnibus Privacy Act states that Electronic Health Records (EHR) ensures the privacy, protection, and security of patient health records. Compliance HIIPAA laws were enacted in 1996 to enhance patient privacy and the security of patient information. Biometrics and encryption are ways to maintain patients’ protected health information (PHI). Firewalls, anti-virus software, password protection, and reCAPTCHA are ways to comply with HIPAA laws. Information Governance Life Cycle Data planning refers to the type of specific data produced, while data inventory and evaluation refers to an extensive collection of data evaluated for accuracy and format; data capture is when data is extracted. Data transformation and processing is manipulating data into readable data for their system. Data access and distribution is having the data from storage and being able to allocate the data. Maintenance is to run diagnostics and correct the data. Archival preservation preserves data for future use, and destruction is the safe deletion of data—the lifecycle, beginning to end. An information governance plan is a framework for organizing specific data interdisciplinary, adhering to legality and regulations, ethically holding personal data, using policy and procedures, governing output information, and storing and releasing data. Data Dictionary

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“A set of descriptions of data items in a data model for reference for systems users.” (Oachs & Watters, 2020). Inside a data dictionary, you will find the patients’ data and patient demographics, such as the patient’s name, diagnosis, diagnosis codes, and medical record number, which varies by patient and date of birth, among other attributes. All this information facilitates the search and identification of the patient. Manage and Maintain Managing and maintaining the information is imperative for the institution because it would not be easily accessible. Interoperability is supported, and synchronized maintenance is needed for proper safekeeping and administration of the data dictionary. Vocabulary Standards It is essential to have vocabulary standards for computers to understand clinical observations. LOINC (Logical Observation Identifiers Names and Codes) is a universal code system for that purpose; SNOMED-CT is also an example of another. Being able to put words into a standard vocabulary coding system is invaluable in the use of EHRs. Data Standardization Data standardization ensures data elements and codes can be communicated. The data dictionary also provides data from other facilities within the HIE to communicate efficiently. Typical uniformity allows for the ease of transferring data to another entity, all speaking the same language.

References Houser, S. H., Slovensky, D. J., & Wang, L. (2017). Information Governance for Analytics Support: Remember the Life Cycle Component. Journal of AHIMA , 88 (6), 38–40. Oachs, P. K., & Watters, A. (2020). Health information management: concepts, principles, and practice. (6th ed.). Ahima, American Health Information Management Association. Vreeman, D. J., & Richoz, C. (2015). Possibilities and implications of using the ICF and other vocabulary standards in electronic health records. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy , 20 (4), 210. https://doi.org/10.1002/pri.1559

HIM 350 Milestone Two

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