Organizations should ensure:
x Staff receives education and training so that data capture
is consistent across the organization.
x Staff understands the ability to change a data dictionary
must be coordinated through the proper change man-
agement procedures. For example, the HIM department
would be able to change a data element format only in co-
ordination with IT security provisions.
x Funding for maintenance and oversight of the data dic-
tionary and data quality management processes.
x Each employee takes ownership of data integrity and un-
derstands how his or her actions affect it.
Whether a data field is being added to an interface or a patient is being registered for the first time, all staff should have a
clear understanding of the data definitions and values and the
implications of inaccurate data entry. The references at the end
of this practice brief can be used to support ongoing education
and training efforts.
HIM’s Role and Responsibility
As information managers, HIM professionals play an important
role in ensuring data integrity. They promote the importance of
data quality, and they understand the healthcare record’s many
functions and the data quality management model’s characteristics.
Regardless of the work setting, HIM professionals must be
actively involved in software selection and management processes. They must take an active role in defining attributes of
prospective applications, as well as maintaining a data integrity
program. Many HIM professionals are also responsible for data
management and report writing.
When additional services are added to the facility or a field
is proposed in the EHR, it is critical to involve an HIM profes-
sional responsible for maintaining the data dictionary or have
the decisions approved by the data quality steering committee
to ensure the impacts are clearly understood.†
In many organizations, the process may be referred to as data
administration. Data administration may be defined as the
“analysis, classification and maintenance of an organization’s
data and data relationships. It includes the development of data
models and data dictionaries…” 6
Many organizations have identified the data (or resource) administrator as an IT role. However, this role is a natural progression for an HIM professional working for or with IT to define,
manage, and coordinate data dictionaries. The data administrator role is typically included as a part of the overarching data
governance program.
Responsibilities of data administrators related to maintaining
data dictionaries include:
x Identifying and promoting clear and valid definitions for
enterprise data
x Identifying and further defining required validation rules
to be applied when capturing enterprise data
x Assessing and resolving data integrity issues (quality,
timeliness, accuracy, completeness) and cost-effective-
ness issues
x Leading training and educational activities of end users to
promote best practices in data collection and use
The foundation established above supports a data administra-
tor’s larger responsibilities, which include:
Notes
1. International Organization for Standardization. “
Information Technology Parts 1–6 (2nd Edition).” 2004. www.iso.
org.
2. Department of Education, Student Aid. “Enterprise Data
Dictionary Standards.” April2007.ht tp://federalstuden-taid.ed.gov/static/gw/docs/ciolibrary/ECONOPS_Docs/
EDM-EnterpriseDataDictionaryStandards.pdf.
3. AHIMA. “Data Mapping Best Practices.” Journal of AHIMA
82, no. 4 (Apr. 2011): 46–52.
4. Ulmer, Stephen E., and Jan C. Fuller. “Understanding the
Meaningful Use Vocabulary Standards.” Journal of AHIMA
81, no. 11 (Nov.–Dec. 2010): 48–49.
5. AHIMA. “Data Quality Management Model.” June 1998.
Available in the AHIMA Body of Knowledge at www.ahima.org.
6. Brunson, Duffie. “Data Quality and Data Governance:
The Basics.” February 15, 2005. www.b-eye-network.com/
view/630.
Resources
All resources available in the AHIMA Body of Knowledge at www.
ahima.org.
AHIMA. “Data Quality Attributes Grid” in “HIM Principles in
Health Information Exchange” (online version). September
2007.
AHIMA. “Health Data Analysis Toolkit.” 2011.
AHIMA e-HIM Work Group on EHR Data Content. “Guidelines
for Developing a Data Dictionary.” Journal of AHIMA 77, no.
2 (Feb. 2006).
AHIMA. “Leadership Model: Data Content Standards.”
AHIMA. “Accountable Care: Implications for Managing Health
Information.” 2011.
Birnbaum, Cassi. “One-stop Shop: An HIM Department’s
Journey to Centralize Core Data Services.” Journal of AHIMA
78, no. 8 (Sept. 2007).
