Below are points that must be consider in your discussion?
� How data quality is improved by the use of standardized terminologies?
� How data quality requirements may be included in organizational policies or processes.
� How standardized terminologies impact the way statistical data is gathered.
� How standardized terminologies influence clinical documentation and practice.
� How movement toward standardized clinical vocabularies and terminologies serves as a
foundation for the National Health Information Network (NHIN).
� Why standardized terminologies are critical to large health information exchanges.
C. If you use sources, include all in-text citations and references in APA format.STOP. See
notes below
Health Care across the Continuum-Data Management
Annotated Bibliography
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Association for the Health Care Development Integrity (Ahdi) (2011). “Healthcare
Documentation Quality Assessment and Management Best
Practices”. Available on
http://www.ahdionline.org/LinkClick.aspx?fileticket=f3sQg96ixiQ%3D&tabid=601
This journal articulates that the evolution and subsequent development of technology in
addition to effective policies in health care will transform the information processes in the health
sector from manual based records to electronic forms as the basic medium by 2015. Pertaining to
these advances, ensuring quality patience records will be paramount when focusing on the
patient’s safety and improved outcomes. Additionally, this journal posts that standardized
approach to report, measuring and improvement to the general documentation of health records
will be beneficial to both the service providers as well as the internal departments. According to
this journal, practitioners in the health sector and all those concerned should follow the principals
of quality in the health documentation process. These principles of quality in relation to this
healthcare documentation are defined as an inclusive code of conduct, which ensure the
accessibility, accuracy, as well as the overall value of the health record in understanding the
patient’s condition, treatment process and progress.
In ensuring that the information entered in the health records would be beneficial to all
the end users, the principles that should be applied include verifiability; meaning that the result
could be easily verified by either service providers or customers. The result should be clear
without any ambiguity. Another element is definability. Defining errors make it easy for the end
uses to understanding the nature of the error. This in turn makes it easy for the production of
quality medical records. Measurability principle pertains to the requirement that the health
documentation allows the end users to understand the formula employed in their calculation.
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Consistency value on the other hand requires that assessment programs on health records
produce consistency. Lastly, integrity should be enhanced at all times when formulating the
records.
American Health Information Management Association (AHIMA) (2010). “Meaningful Use
Vocabulary Toolkit” Available on
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048346.pdf
This journal articulates that in reaching the status of interoperability that is required in
improving the health care system, the electronic record system must be tailored to offer semantic
interoperability. Semantic interoperability in this case refers to the ability of computers systems
in recording, exchanging and even interpreting data with regard to its meaning and not just its
surface state. However, this interoperability is not sufficient by simply possessing the ability to
convey data, but another requirement that both the senders and the recipient of the information
convey the same meaning of the information. The authors add that presently, they is a need of
capturing and encoding health information and the practitioners are encouraged to embrace the
present perspective of world sets.
The authors further add that for an enhanced data quality in the health sector, the health
practitioners and those concerned should be conversant with the language and vocabulary
standards t that were adopted by ONC. These regulations pertain to code sets, vocabularies, and
nomenclatures in the health sector. If applied effectively, they will enable an efficient collection
of primary information for either external purposes or internal use. The journal defines a
qualified EHR as an electronic record of health data, including the patient’s clinical information
such as his or her medical history and list of problems. A qualified EHR is also considered as
one that is capable of proving clinical decisions, is able to support the practitioner’s entry order,
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able to collect and query data in relation to the quality of the health care and finally, capable of
exchanging and interrelating such information from other sources.
American Medical Association (2010). “Using a Medical Data Dictionary to Comply with
Vocabulary
Standards and Exchange Clinical Data
The authors in this journal observe that the present state of communication in the health
sector involving information technology has its own share of huddles. These problems as
identified in this journal range from uncertainty and ambiguity among other issues. These
instances as they note have compromised the efficacy, safety as well as the efficient of the
operations in many health departments. The standard vocabulary, which these health professional
employ, could influence how information is relayed in these organization or the EHR system.
According to this journal, there are right medical vocabularies that practitioners are supposed to
employ in any health related organization so as to make this information accessible, describable
and even sensible to all the end users.
The authors however articulate that there is no particular medical vocabulary that could
solve all the needs of the end users. This is because each terminology that these people are
expected to use was designed for different purposes in the different department of the healthcare.
Owing to this aspect therefore, an integration of a structured terminology system is paramount so
as to mediate the differences emanating between these vocabularies and code sets. This will
facilitate the effective incorporation of these vocabularies in the clinical information system. In
this perspective, a medical data dictionary according this journal would be an important
companion to the health practitioner since; it is tailored to support both the health information
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systems and the electronic health records. In addition, a medical data dictionary which is well
designed may enhance the vocabulary standards of an HER System or a health organization and
exchange information which is received in all many formats as well as the vocabularies from
different sources or systems.
References
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American Medical Association (2010). “Using a Medical Data Dictionary to Comply with Vocabulary
Standards and Exchange Clinical Data”
American Health Information Management Association (AHIMA) (2010). “Meaningful Use
Vocabulary Toolkit”
Association for the Health Care Development Integrity (Ahdi) (2011). “Healthcare
Documentation Quality Assessment and Management Best
Practices”.