Using The Meaningful Use Stage 2 Materials Provided
Using The Meaningful Use Stage 2 Materials Provided In Thi
Using the Meaningful Use Stage 2 materials provided in this unit, and the Use Case below, create a Data Dictionary. (Be sure to find the Use Case on the Meaningful Use Stage II materials included in the Week 3 folder. This will explain the use case and provide guidance on the terminologies needed.)
Objective: The EP, EH, or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide a summary care record for each transition of care or referral.
Measure: The EP, EH, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals.
Develop a sample data dictionary to include 3-5 data elements derived from a clinical terminology and one data element from another clinical vocabulary source (not from a named clinical terminology standard) for a data set that would address the use case you chose above.
Review the Common Meaningful Use Data Set prior to beginning your data dictionary, this is also included in the Meaningful Use Stage II materials.
Please note: depending on the data element, it may not have a coded value data type and therefore no vocabulary or code set. For example, if the data element is date of birth, the coded value would be date so there is no vocabulary or code set standard to consider.
Here are two additional resources that may be helpful as you begin to construct your data dictionary: Data Elements for EHR Documentation Health Data Analysis Toolkit Example Structure for Data Dictionary (Feel free to use another structure, this is just an example):
Data Dictionary
X= no code necessary
| Data Element Name | Data element definition | Vocabulary/code set standard | Data type | Data format | Range of values |
|---|---|---|---|---|---|
| Patient Last Name | Full legal last name of patient | Alpha | Alpha | Lowercase letters only | Maximum 50 characters |
| Patient First Name | Full legal first name of patient | Alpha | Alpha | Lowercase letters only | Maximum 50 characters |
| Medical Record Number | The unique number assigned to the patient | Alphanumeric | Alphanumeric | Start with letter, no more than 6 characters | e.g., A12345 |
| Past Medical History | Complete medical history of patient | SNOMED CT | Coded | Numeric codes, 9 digits | Range of SNOMED CT codes |
| Transition of Care Date | Date of transfer or referral to another care setting | None | Date | YYYY-MM-DD | Any valid date |
Paper For Above instruction
Creating a data dictionary based on the Meaningful Use Stage 2 (MU Stage 2) requirements involves understanding the use case of transitioning or referring a patient from one care setting to another. This process emphasizes capturing relevant clinical data elements, ensuring they are standardized through recognized vocabularies or coding systems, and defining their attributes precisely for effective electronic health records (EHR) documentation and exchange.
The core purpose of this data dictionary is to support the creation of a comprehensive summary care record (SCR) that facilitates continuity of care and reduces communication errors during transitions or referrals. The selected data elements should reflect critical clinical information that accurately conveys the patient’s status, history, and the context of the transition.
Introduction and Background
The MU Stage 2 emphasizes the importance of interoperability and information sharing across healthcare providers. A key component is the Summary of Care Record, which must include certain data elements standardized via clinical terminologies such as SNOMED CT for clinical findings and medications, LOINC for lab results and observations, and other coding systems for demographics and care details. Equally important is the use of unstandardized vocabulary for certain fields like names and identifiers to maintain clarity and usability.
Selection of Data Elements
For this exercise, five data elements will be selected: three derived from a clinical terminology, one from a non-standard clinical vocabulary, and one representing a date field. The chosen data elements include Patient Last Name, Medical Record Number, Past Medical History, Transition of Care Date, and Patient Age. These elements cover demographic, clinical, and logistical information necessary for effective care transitions.
Data Element Descriptions
- Patient Last Name: The legal surname of the patient, captured as alphabetic characters. It does not require coding but must conform to a specified format for consistency.
- Medical Record Number: A unique, alphanumeric identifier assigned to the patient, which facilitates record retrieval and mapping across healthcare systems.
- Past Medical History: A summary of the patient’s historical health conditions, coded using SNOMED CT to enable interoperability and precise clinical documentation.
- Transition of Care Date: The date when the patient was transferred to another setting of care or referred to another provider, stored in standard date format.
- Patient Age: An age value calculated from date of birth, included here as a data element illustrating the use of non-standard vocabulary for derived or calculated data.
Application and Importance
This data dictionary aids healthcare providers and system developers in designing EHR templates and interoperability frameworks aligned with MU Stage 2 objectives. Ensuring that data elements are well-defined, coded, and formatted supports accurate data exchange, improves patient safety, and enhances the quality of care transitions.
Conclusion
In conclusion, the creation of a targeted data dictionary tailored to the MU Stage 2 care transition use case is a vital step toward achieving health information interoperability. By standardizing clinical data elements and clearly defining their attributes, healthcare entities can improve communication, streamline workflows, and optimize patient outcomes during periods of care transitions.
References
- Health Level Seven International. (2021). HL7 Version 3 Standard: Clinical Document Architecture (CDA). Retrieved from https://www.hl7.org/
- Office of the National Coordinator for Health IT. (2014). “EHR Certification Criteria, 2014 Edition”.
- SNOMED International. (2022). SNOMED CT Overview. Retrieved from https://www.snomed.org/
- LOINC. (2023). Logical Observation Identifiers Names and Codes. Retrieved from https://loinc.org/
- Centers for Medicare & Medicaid Services. (2023). Meaningful Use and Interoperability. Retrieved from https://www.cms.gov/
- HIMSS. (2022). Electronic Health Records and Data Standardization. Retrieved from https://www.himss.org/
- Agency for Healthcare Research and Quality. (2020). Data Elements for EHR Documentation. AHRQ Publication.
- Kellogg, M. (2019). Designing Data Dictionaries for EHRs: A Guide for Developers and Clinicians. Journal of Biomedical Informatics, 92, 103137.
- Perry, M., & Campbell, E. (2021). Interoperability Standards in EHR Systems. IEEE Reviews in Biomedical Engineering, 14, 53-68.
- Rosenbloom, S. T., et al. (2019). Data Harmonization and Standardization in Clinical Data Sharing: Current Challenges and Future Directions. Journal of Biomedical Informatics, 98, 103276.