HIM 685 Module 3 Data Dictionary Example

What Longleaf Sends: A Data Dictionary for the Statewide Exchange Feed, Built on Industry Standards

[Student Name]

Southern New Hampshire University

HIM 685: Advanced Topics in HIM II

Module Three Data Dictionary

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[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

What Longleaf Sends: A Data Dictionary for the Statewide Exchange Feed, Built on Industry Standards

A data dictionary is the agreement that lets two systems mean the same thing by the same data. When the composite Longleaf hospital starts transmitting data to the statewide exchange, every element it sends must be defined, coded to a standard the exchange expects and checked before it leaves. The DAMA body of knowledge treats a data dictionary as a core part of metadata management, the information that makes data understandable and usable by others (DAMA International, 2017). This dictionary covers the twelve elements Longleaf will send in its first phase and explains, for each, why it matters to the patient record that a clinician elsewhere will see.

Scope and Structure

The first phase covers three feeds: admission, discharge and transfer notices; laboratory results, both sent to the exchange's central repository; and discharge summary documents, held on Longleaf's server and retrieved on request. Each entry records eight attributes: the element's name, a plain definition, the industry standard that governs it, the expected format, the source system at Longleaf, whether the exchange requires it, a quality rule that is checked before sending and the steward responsible. Element choices follow the federal core data set for interoperability, which lists the data classes certified systems should be able to exchange, including patient demographics, laboratory results, problems and medications (Office of the National Coordinator for Health Information Technology, n.d.).

The Dictionary

Table 1 presents the twelve elements. Quality rules are written so that a feed can test them automatically before data leave the hospital.

Table 1. Data Dictionary for the Statewide Exchange Feed, Phase One

Note. Stewards: registration manager for identity elements, laboratory information manager for lab elements and the HIM director for diagnoses, medications and documents.

Identity Elements and Matching

The first five elements exist to find the right patient. The exchange's master patient index compares them across members to judge whether two charts describe one individual, so their quality matters more than any clinical element. A placeholder name or an invented date of birth can cause a false match, attaching one patient's results to another, or a missed match, leaving a patient's history invisible. That is why the quality rules exclude placeholder names from the final feed and require valid dates and coded sex. Longleaf's two clinic systems currently assign different numbers to the same patients; until they are linked, the hospital will send only its enterprise identifier, so that the exchange never receives two identities for one person from Longleaf.

Encounter and Clinician Elements

Admission, discharge and transfer notices tell other clinicians and care managers that a patient has entered or left the hospital. Their value depends on speed: a notice that arrives a day late cannot prompt a primary care follow-up call within the window that matters. The quality rule therefore measures timeliness, not only presence. The attending clinician is identified by National Provider Identifier rather than by name, because names are not unique and change, while the identifier can be checked automatically and linked to a directory across the state.

Clinical Elements and Their Standards

Laboratory tests are coded in LOINC, which identifies observations unambiguously so that a potassium result from Longleaf means the same as one from any other member. Units follow UCUM, the unified code for units, so that a receiving system can compare values without guessing. Problems are coded in SNOMED CT for clinical meaning, with ICD-10-CM retained for billing diagnoses, and medications in RxNorm, which names drugs at the level clinicians and pharmacists use. Benson and Grieve (2021) explain that interoperability depends on agreement about both message structure and terminology; a well-formed HL7 message with local codes inside still cannot be understood elsewhere. The discharge summary follows the consolidated clinical document architecture, an HL7 standard that structures documents into sections a receiving system can display or parse.

Patient Record Relevance

Each element earns its place by what it does for patient care elsewhere. Admission notices let a primary care practice call a patient within days of discharge. Lab results let an emergency physician avoid repeating a test drawn hours earlier. Coded problems and medications let a receiving clinician reconcile a patient's list rather than retyping it. The discharge summary gives the narrative that explains the numbers. Elements were excluded when their value did not justify their risk or effort in the first phase; for example, free-text nursing notes stay out because they are long, rarely standardized and more likely to contain sensitive details that patients did not expect to be shared.

Quality Checks and Maintenance

The quality rules map to the conformance, completeness and plausibility categories described by Kahn et al. (2016): coded values and formats test conformance, required fields test completeness and rules such as a birth date not in the future test plausibility. Messages that fail a rule will be held in a queue for the steward instead of being sent. The dictionary will be reviewed every six months and whenever the exchange or the federal core data set changes, with every change dated and approved by the HIM director.

Conclusion

This dictionary turns the statewide exchange's expectations into twelve definitions Longleaf can test and defend. Its most important entries are the plainest ones, name, birth date and identifier, because the clinical value of everything else depends on finding the right patient.

References

Benson, T., & Grieve, G. (2021). Principles of health interoperability: FHIR, HL7 and SNOMED CT (4th ed.). Springer.

DAMA International. (2017). DAMA-DMBOK: Data management body of knowledge (2nd ed.). Technics Publications.

Kahn, M. G., Callahan, T. J., Barnard, J., Bauck, A. E., Brown, J., Davidson, B. N., Estiri, H., Goerg, C., Holve, E., Johnson, S. G., Liaw, S.-T., Hamilton-Lopez, M., Meeker, D., Ong, T. C., Ryan, P., Shang, N., Weiskopf, N. G., Weng, C., Zozus, M. N., & Schilling, L. (2016). A harmonized data quality assessment terminology and framework for the secondary use of electronic health record data. eGEMs, 4(1), Article 1244. https://doi.org/10.13063/2327-9214.1244

Office of the National Coordinator for Health Information Technology. (n.d.). United States Core Data for Interoperability (USCDI). https://www.healthit.gov/isp/united-states-core-data-interoperability-uscdi