Imagine you are an HIM Compliance Manager for a large hospital system, and you are responsible for the integration of new clinical data into your existing electronic health record (EHR). During your research of clinical process modeling, you learned about how healthcare data sets and dictionaries are used in the hospital settings. For example, hospitals utilize the Uniform Hospital Discharge Data Set (UHDDS) which is considered a core data set for hospital reporting. The UHDDS contains a data dictionary where the principal diagnosis, a data element, is defined along with its allowable value, an ICD-10 CM code.
Based on your knowledge, create a data integration strategy that will ensure data are in a format that will satisfy the hospital’s integration needs. In addition, the hospital system recently added several, new applications to complement their Electronic Health Record (EHR). One of the applications is Computer Assisted Coding where Natural Language Text Processing (NLP) will be applied. Voice Recognition and document imaging will also be applied as innovative data capture applications. Utilize this unit’s readings and other resources found on the internet and the Library.
Your data integration strategy should be 8 pages in length and cover all of the following elements:
- Ensure the standardization of data dictionaries to meet the needs of the enterprise.
- Establish data architectural models for the enterprise.
- Apply data capture technologies: Natural Language Text Processing (NLP),
voice recognition, and document imaging.
- Demonstrate applicable clinical data standards theory and development.
- Data standards are in place that allow healthcare providers to share information through the use of the same language like we have been discussing with SNOMED-CT, LOINC, RXnorm. It is through the standardized language that the information becomes interoperable. Standards are developed by HL7 and other SDOs and include terminology standards, data exchange standards, and privacy/security standards.
- Ensure data are in a format that will satisfy data integration needs:
• Decision support
• Legacy systems
- Describe clinical data and clinical process modeling:
• UML-Unified Modeling Language
• UP-Unified Process
- Develop enterprise wide policies and procedures for collection, use, and maintenance of health care data.
- Enable decision-makers to use data
- It is through the use of data that effective decision making can be done. By having clinical data standards, information can be shared in order to treat patients, for example if a patient is in the ED at one hospital, and has medical records with their GP that provides medications and allergies the ED can access this information through interoperability and have the necessary data to make decisions when treating the patient.
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