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practice guidelines for managing health information
IN RECENT YEARS, the American Recovery and Reinvestment Act, numerous health IT initiatives, and the growth of health information exchange (HIE) have increased the healthcare industry's focus on data management and data use. Currently many organizations store data in multiple health information systems that are disparate - meaning the data within each system stand alone and are not interoperable. The data may or may not be collected consistently.
This lack of data consistency can create challenges for data comparison and reporting for initiatives such as those outlined above and can lead to errors in data use.
Accurate and reliable data are integral to the many health IT initiatives currently under way. According to the International Organization for Standardization (ISO):
The increased use of data processing and electronic data interchange heavily relies on accurate, reliable, controllable, and verifiable data recorded in databases. One of the prerequisites for a correct and proper use and interpretation of data is that both users and owners of data have a common understanding of the meaning and descriptive characteristics (e.g., representation) of that data. To guarantee this shared view, a number of basic attributes has to be defined.1
A data dictionary is one tool organizations can use to help ensure data accuracy.
This practice brief describes common data inconsistencies found within healthcare organizations' systems and defines the data dictionary and its associated data management challenges. It also outlines best practices for maintaining data integrity, including the HIM professional's role.
Common Data Inconsistencies
In many organizations data are stored in different databases and may be of inconsistent quality. Issues such as variable naming conventions, définitions, field length, and element values can all lead to misuse or misinterpretation of data in reporting. The following examples illustrate common data inconsistencies.
Inconsistent naming conventions. The date of the patient's admission is referred to differently in different systems: "Date of Admission" in the patient management module within the EHR, "Admit Date" in the fetal monitoring system, and "Admission Date" in the cardiology database. The unique patient identifier is referred to as a "Medical Record Number" in the patient management system, "Patient Record Identifier" in the operating room system, "A number" (a moniker leftover from a legacy system from 25...