Expert answer:Data Dictionary Use Case
Solved by verified expert:20 Points Assignment Instructions, Requirements, and Evaluation: 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 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.Below is some information that may help answer questions about the assignment:Construct a data dictionary for the elements in the data set. Include the data element name, data element description/definition, vocabulary or code set standard for the data element if applicable, data type (text, coded values, etc.), data format, and range of values.Make sure to cite your sources! You are not expected to include specific ranges of codes (data dictionary range of values). For example, if you useSNOMED CT, the clinical finding hierarchy contains the range of codes for diseases and findings which would be the type of content found on a problem list. Thus, if SNOMED CT is one of your vocabulary standards listed in your data dictionary, you would note clinical finding hierarchy for the range of values. Here are two additional resources that may be helpful as you begin to construct your data dictionary: Data Elements for EHR Documentation http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_034460.hcsp?dDocName=bok1_034460 Health Data Analysis Toolkit http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048618.pdf 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 Demographic Information —————- —————— ————— —————– —————— Last Name Full legal last name of patient X Alpha abcdefghijklm X Full First Name Full legal first name of patient X Alpha abcdefghijklm X Medical Record Number The unique number assigned to the patient X Alphanumeric Must start with letter and not more than 6 number A123456 Clinical Information ————— —————— —————— —————— —————— Past Medical History Complete medical history of patient SNOMED CT Coded 9 numbers 70753007
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CORE
EP EH
EP
EH
MEANINGFUL
USE
MEANINGFUL
USE
Stage 2 Objective
Stage 2 Measure
42 CFR 495.6(j)-(m)
42 CFR 495.6(j)-(m)
2014 Edition EHR
CERTIFICATION CRITERIA
STANDARDS
45 CFR 170.314
More than 60% of medication,
§170.314(a)(1)
30% of laboratory, and 30% of
radiology orders created by the EP Computerized provider order entry. Enable a user to electronically record, change, and access
Use CPOE for medication,
or authorized providers of the EH’s the following order types, at a minimum:
laboratory and radiology orders or CAH’s inpatient or emergency
Medications;
directly entered by any licensed department (POS 21 or 23) during (i)
(ii) Laboratory; and
healthcare professional who
the EHR reporting period are
(iii) Radiology/imaging.
can enter orders into the
recorded using CPOE.
medical record per State, local
and professional guidelines.
EP
CORE
CORE
CORE
*Exclusions apply: see CMS rule for
details
EH
EP
EH
EPs: Record the following
demographics:
• Preferred language
• Sex
• Race
• Ethnicity
• Date of birth.
EHs/CAHs: Record the following
demographics:
• Preferred language
• Sex
• Race
• Ethnicity
• Date of birth
• Date and preliminary
cause of death in the
event of mortality in the EH
or CAH.
Record and chart changes in
vital signs:
• Height/length
• Weight
• Blood pressure (BP)
(age 3+)
• Calculate and display BMI
• Plot and display growth
charts for children 0–20
years, including BMI.
§170.314(a)(3)
More than 80% of all unique
patients seen by the EP or
admitted to the EH’s or CAH’s
inpatient or emergency
department (POS 21 or 23) during
the EHR reporting period have
demographics recorded as
structured data.
More than 80% of all unique
patients seen by the EP or
admitted to the EH’s or CAH’s
inpatient or emergency
department (POS 21 or 23) during
the EHR reporting period have BP
(for patients age 3+ only) and
height/length and weight (for all
ages) recorded as structured data.
*Exclusions apply: see CMS rule for
details
Demographics.
(i)
Enable a user to electronically record, change, and access patient demographic data
including preferred language, sex, race, ethnicity, and date of birth.
A.
Enable race and ethnicity to be recorded in accordance with the standard specified
in § 170.207(f) and whether a patient declines to specify race and/or ethnicity.
B.
Enable preferred language to be recorded in accordance with the standard specified
in § 170.207(g) and whether a patient declines to specify a preferred language.
(ii)
Inpatient setting only. Enable a user to electronically record, change, and access
preliminary cause of death in the event of a mortality.
§ 170.207(f) – OMB standards
for Maintaining, Collecting, and
Presenting Federal Data on
Race and Ethnicity, Statistical
Policy Directive No. 15, Oct 30,
1997.
§ 170.207(g) – ISO 639-2
alpha-3 codes limited to those
that also have a corresponding
alpha-2 code in ISO 639-1.
§170.314(a)(4)
Vital signs, body mass index, and growth charts.
(i)
Vital signs. Enable a user to electronically record, change, and access, at a minimum, a
patient’s height/length, weight, and blood pressure. Height/length, weight, and blood
pressure must be recorded in numerical values only.
(ii) Calculate body mass index. Automatically calculate and electronically display body mass
index based on a patient’s height and weight.
(iii) Optional – Plot and display growth charts. Plot and electronically display, upon request,
growth charts for patients.
#Unofficial Recitations of Portions of 42 CFR Part 495 and 45 CFR Part 170#
Note: Please consult CMS’s regulatory requirements for meaningful use at 42 CFR Part 495 for the full suite of requirements that may need to be met to satisfy an objective and measure.
-1-
CORE
EP EH
EP
EH
MEANINGFUL
USE
MEANINGFUL
USE
Stage 2 Objective
Stage 2 Measure
42 CFR 495.6(j)-(m)
Use clinical decision support to
improve performance on highpriority health conditions.
42 CFR 495.6(j)-(m)
1. Implement five clinical decision
support interventions related to
four or more clinical quality
measures at a relevant point in
patient care for the entire EHR
reporting period. Absent four
clinical quality measures
related to an EP’s, EH’s, or
CAH’s scope of practice or
patient population, the clinical
decision support interventions
must be related to high-priority
health conditions. Absent four
clinical quality measures
related to [an EP’s scope of
practice or patient
population/an eligible hospital
or CAH’s patient population],
the clinical decision support
interventions must be related
to high-priority health
conditions.
2. The EP, EH, or CAH has enabled
and implemented the
functionality for drug-drug and
drug-allergy interaction checks
for the entire EHR reporting
period.
*Exclusions apply: see CMS rule for
details
2014 Edition EHR
CERTIFICATION CRITERIA
STANDARDS
45 CFR 170.314
§170.314(a)(8) / §170.314(a)(2)
Clinical decision support.
(i)
Evidence-based decision support interventions. Enable a limited set of identified users to select
(i.e., activate) one or more electronic clinical decision support interventions (in addition to drugdrug and drug-allergy contraindication checking) based on each one and at least one
combination of the following data:
(A) Problem list;
(B) Medication list;
(C) Medication allergy list;
(D) Demographics;
(E) Laboratory tests and values/results; and
(F)
Vital signs.
(ii)
Linked referential clinical decision support.
(A) EHR technology must be able to:
(1) Electronically identify for a user diagnostic and therapeutic reference information; or
(2) Electronically identify for a user diagnostic and therapeutic reference information in
accordance with the standard specified at § 170.204(b) and the implementation
specifications at § 170.204 (b)(1) or (2).
(B) For paragraph (a)(8)(ii)(A) of this section, EHR technology must be able to electronically
identify for a user diagnostic or therapeutic reference information based on each one and
at least one combination of the data referenced in paragraphs (a)(8)(i)(A) through (F) of
this section.
(iii) Clinical decision support configuration.
(A) Enable interventions and reference resources specified in paragraphs (a)(8)(i) and (ii) of
this section to be configured by a limited set of identified users (e.g., system administrator)
based on a user’s role.
(B) EHR technology must enable interventions to be electronically triggered:
(1) Based on the data referenced in paragraphs (a)(8)(i)(A) through (F) of this section.
(2) When a patient’s medications, medication allergies, and problems are incorporated
from a transition of care/referral summary received pursuant to paragraph (b)(1)(iii)
of this section.
(3) Ambulatory setting only. When a patient’s laboratory tests and values/results are
incorporated pursuant to paragraph (b)(5)(i)(A)(1) of this section.
(iv) Automatically and electronically interact. Interventions triggered in accordance with paragraphs
(a)(8)(i)-(iii) of this section must automatically and electronically occur when a user is interacting
with EHR technology.
(v)
Source attributes. Enable a user to review the attributes as indicated for all clinical decision
support resources:
(A) For evidence-based decision support interventions under paragraph (a)(8)(i) of this section:
(1) Bibliographic citation of the intervention (clinical research/guideline);
(2) Developer of the intervention (translation from clinical research/guideline);
(3) Funding source of the intervention development technical implementation; and
(4) Release and, if applicable, revision date(s) of the intervention or reference source.
(B) For linked referential clinical decision support in paragraph (a)(8)(ii) of this section and
drug-drug, drug-allergy interaction checks in paragraph(a)(2) of this section, the developer
of the intervention, and where clinically indicated, the bibliographic citation of the
intervention (clinical research/guideline).
Drug-drug, drug-allergy interaction checks.
1.
Interventions. Before a medication order is completed and acted upon during computerized
provider order entry (CPOE), interventions must automatically and electronically indicate to a
user drug-drug and drug-allergy contraindications based on a patient’s medication list and
medication allergy list.
2.
Adjustments.
(A) Enable the severity level of interventions provided for drug-drug interaction checks to be
adjusted.
(B)
Limit the ability to adjust severity levels to an identified set of users or available as a
system administrative function.
§ 170.204(b) – HL7 V3
Standard: Context-Aware
Retrieval Application
(Infobutton).
Implementation specifications:
§ 170.204(b)(1) – HL7 V3 IG:
URL-Based Implementations of
Context-Aware Information
Retrieval (Infobutton) Domain;
or § 170.204(b)(2) – HL7 V3
IG: Context-Aware Knowledge
Retrieval (Infobutton) ServiceOriented Architecture
Implementation Guide.
#Unofficial Recitations of Portions of 42 CFR Part 495 and 45 CFR Part 170#
Note: Please consult CMS’s regulatory requirements for meaningful use at 42 CFR Part 495 for the full suite of requirements that may need to be met to satisfy an objective and measure.
-2-
CORE
EP EH
EP
EH
MEANINGFUL
USE
MEANINGFUL
USE
Stage 2 Objective
Stage 2 Measure
42 CFR 495.6(j)-(m)
Record smoking status for
patients 13 years old or older.
42 CFR 495.6(j)-(m)
2014 Edition EHR
CERTIFICATION CRITERIA
STANDARDS
45 CFR 170.314
More than 80% of all unique
patients 13 years old or older seen
by the EP or admitted to the EH’s
or CAH’s inpatient or emergency
department (POS 21 or 23) during
§170.314(a)(11)
the EHR reporting period have
smoking status recorded as
Smoking status. Enable a user to electronically record, change, and access the smoking status
structured data.
of a patient in accordance with the standard specified at § 170.207(h).
§ 170.207(h) – Coded to one
of the following SNOMED CT®
codes:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
*Exclusions apply: see CMS rule for
details
(8)
Current every day smoker.
449868002
Current some day smoker.
428041000124106
Former smoker. 8517006
Never smoker. 266919005
Smoker, current status
unknown. 77176002
Unknown if ever smoked.
266927001
Heavy tobacco smoker.
428071000124103
Light tobacco smoker.
428061000124105
CORE
CORE
§170.314(a)(14)
EP
EP
EH
Patient list creation. Enable a user to electronically and dynamically select, sort, access, and
create patient lists by: date and time; and based on each one and at least one combination of
the following data:
(i)
Problems;
(ii) Medications;
(iii) Medication allergies;
(iv) Demographics;
(v) Laboratory tests and values/results; and
(vi) Ambulatory setting only. Patient communication preferences.
Generate lists of patients by
specific conditions to use for
quality improvement, reduction
of disparities, research, or
outreach.
Generate at least one report listing
patients of the EP, EH, or CAH with
a specific condition.
Use clinically relevant
information to identify patients
who should receive reminders
for preventive/follow-up care
and send these patients the
reminder, per patient
preference.
§170.314(a)(14)
More than 10% of all unique
patients who have had two or
more office visits with the EP
Patient list creation. Enable a user to electronically and dynamically select, sort, access, and
within the 24 months before the
create patient lists by: date and time; and based on each one and at least one combination of
beginning of the EHR reporting
the following data:
period were sent a reminder, per
Problems;
patient preference when available. (i)
(ii)
Medications;
(iii)
Medication allergies;
(iv)
Demographics;
*Exclusions apply: see CMS rule for (v)
Laboratory tests and values/results; and
details (vi)
Ambulatory setting only. Patient communication preferences.
#Unofficial Recitations of Portions of 42 CFR Part 495 and 45 CFR Part 170#
Note: Please consult CMS’s regulatory requirements for meaningful use at 42 CFR Part 495 for the full suite of requirements that may need to be met to satisfy an objective and measure.
-3-
CORE
EP EH
EP
EH
MEANINGFUL
USE
MEANINGFUL
USE
Stage 2 Objective
Stage 2 Measure
42 CFR 495.6(j)-(m)
Use clinically relevant
information from CEHRT to
identify patient-specific
education resources and
provide those resources to the
patient.
42 CFR 495.6(j)-(m)
EP: Patient-specific education
resources identified by CEHRT are
provided to patients for more than
10% of all unique patients with
office visits seen by the EP during
the EHR reporting period.
*Exclusions apply: see CMS rule for
details
EHs/CAHs: More than 10% of all
unique patients admitted to the
EH’s or CAH’s inpatient or
emergency departments (POS 21
or 23) are provided patient-specific
education resources identified by
CEHRT.
2014 Edition EHR
CERTIFICATION CRITERIA
STANDARDS
45 CFR 170.314
§170.314(a)(15)
Patient-specific education resources. EHR technology must be able to electronically identify for
a user patient-specific education resources based on data included in the patient’s problem list,
medication list, and laboratory tests and values/results:
(i)
In accordance with the standard specified at § 170.204(b) and the implementation
specifications at § 170.204(b)(1) or (2); and
(ii)
By any means other than the method specified in paragraph (a)(15)(i).
§ 170.204(b) – HL7 V3
Standard: Context-Aware
Retrieval Application
(Infobutton).
Implementation specifications:
§ 170.204(b)(1) – HL7 V3
Implementation Guide: URLBased Implementations of
Context-Aware Information
Retrieval (Infobutton) Domain;
or § 170.204(b)(2) – HL7 V3
Implementation Guide: ContextAware Knowledge Retrieval
(Infobutton) Service-Oriented
Architecture Implementation
Guide.
CORE
§170.314(a)(16)
EH
More than 10% of medication
orders created by authorized
providers of the EH’s or CAH’s
Automatically track medications inpatient or emergency department
from order to administration
(POS 21 or 23) during the EHR
using assistive technologies in reporting period for which all doses
conjunction with an electronic
are tracked using eMAR.
medication administration
record (eMAR).
*Exclusions apply: see CMS rule for
details
Inpatient setting only — electronic medication administration record.
(i) In combination with an assistive technology that provides automated information on the
“rights” specified in paragraphs (a)(16)(i)(A) through (E) of this section, enable a user to
electronically verify the following before administering medication(s):
(A) Right patient. The patient to whom the medication is to be administered matches the
medication to be administered.
(B) Right medication. The medication to be administered matches the medication
ordered for the patient.
(C) Right dose. The dose of the medication to be administered matches the dose of the
medication ordered for the patient.
(D) Right route. The route of medication delivery matches the route specified in the
medication order.
(E) Right time. The time that the medication was ordered to be administered compared to
the current time.
(ii) Right documentation. Electronically record the time and date in accordance with the
standard specified in § 170.210(g), and user identification when a medication is
administered.
170.210(g). The date and time
recorded utilize a system clock
that has been synchronized
following (RFC 1305) Network
Time Protocol, or (RFC 5905)
Network Time Protocol
Version 4.
#Unofficial Recitations of Portions of 42 CFR Part 495 and 45 CFR Part 170#
Note: Please consult CMS’s regulatory requirements for meaningful use at 42 CFR Part 495 for the full suite of requirements that may need to be met to satisfy an objective and measure.
-4-
EP EH
MEANINGFUL
USE
MEANINGFUL
USE
Stage 2 Objective
Stage 2 Measure
42 CFR 495.6(j)-(m)
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 provides a summary care
record for each transition of
care or referral.
CORE
Transitions of care.
EP
EH
42 CFR 495.6(j)-(m)
1. 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.
2. 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 10% of
such transitions and referrals
either – (a) Electronically
transmitted using CEHRT to a
recipient; or (b) Where the
recipient receives the summary
of care record via exchange
facilitated by an organization
that is a NwHIN Exchange
participant or in a manner that
is consistent with the
governance mechanism ONC
establishes for the nationwide
health information network.
3. An EP, EH, or CAH must satisfy
one of the following:
(A) Conducts one or more
successful electronic
exchanges of a summary
of care record meeting
the measure (for EPs at
§ 495.6(j)(14)(ii)(B) and
for eligible hospitals and
CAHs the measure at§
495.6(l)(11)(ii)(B)) with a
recipient using technology
to receive the summary of
care record that was
designed by a different
EHR developer than the
sender’s EHR technology
certified at 45 CFR
107.314(b)(2); or
(B) Conducts one or more
successful tests with the
CMS designated test EHR
during the EHR reporting
period.
2014 Edition EHR
CERTIFICATION CRITERIA
STANDARDS
45 CFR 170.314
§170.314(b)(1) & (b)(2)
Transitions of care: (b)(1) – receive, display, and incorporate transition of care/referral summaries.
(i) Receive. EHR technology must be able to electronically receive transition of care/referral
summaries in accordance with:
(A) The standard specified in § 170.202(a).
(B) Optional. The standards specified in § 170.202(a) and (b).
(C) Optional. The standards specified in § 170.202(b) and (c).
(ii) Display. EHR technology must be able to electronically display in human readable format the data
included in transition of care/referral summaries received and formatted according to any of the
following standards (and applicable implementation specifications) specified in: § 170.205(a)(1),
§ 170.205(a)(2), and § 170.205(a)(3).
(iii) Incorporate. Upon receipt of a transition of care/referral summary formatted according to the
standard adopted at § 170.205(a)(3), EHR technology must be able to:
(A) Correct patient. Demonstrate that the transition of care/referral summary received is or can
be properly matched to the correct patient.
(B) Data incorporation. Electronically incorporate the following data expressed according to the
specified standard(s):
(1) Medications. At a minimum, the version of the standard specified in §170.207(d)(2);
(2) Problems. At a minimum, the version of the standard specified in §170.207(a)(3);
(3) Medication allergies. At a minimum, the version of the standard specified in
§170.207(d)(2).
(C) Section views. Extract and allow for individual display each additional section or sections
(and the accompanying document header information) that were included in a transition of
care/referral summary received and formatted in accordance with the standard adopted at
§ 170.205(a)(3).
Transitions of care: (b)(2) – create and transmit transition of care/referral summaries.
(i) Create. Enable a user to electronically create a transition of care/referral summary formatted
according to the standard adopted at § 170.205(a)(3) that includes, at a minimum, the Common
MU Data Set** and the following data expressed, where applicable, according to the specified
standard(s):
(A) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version
of the standard specified § 170.207(a)(3);
(B) Immunizations. The standard specified in § 170.207(e)(2);
(C) Cognitive status;
(D) Functional status; and
(E) Ambulatory setting only. The reason for referral; …
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