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Data Standards, Data Quality, and Interoperability (2013
update)
Remove from myBoK
Editor's note: This update replaces the 2007 practice brief "Data
Standards, Data Quality, and Interoperability."
Data quality and consistency are critical to ensuring patient safe
ty, communicating delivery of health services, coordinating
care, and healthcare reporting. Assessing the quality and consist
ency of data requires data standards. This practice brief
provides health information management (HIM) professionals w
ith a clear understanding of data standards as a tool to
enable interoperability and promote data quality.
The online version of this practice brief [...] is accompanied by
an appendix that provides HIM professionals with a list of
standards to reference in data dictionary development, electroni
c health records, the exchange of health information, and
general data management processes to ensure information integr
ity and reliability. Evaluation of data validity, reliability,
completeness, and timeliness are accomplished through a combi
nation of human and machine processes in healthcare, and
the list of data standard sources is a helpful reference guide whe
n more detailed information is required.
Data Standards and Regulatory Framework

Data standards are "documented agreements on representations,
formats, and definitions of common data. Data standards
provide a method to codify invalid, meaningful, comprehensive,
and actionable ways, information captured in the course of
doing business."
Rules to describe how the data is recorded to ensure consistenc
y across multiple sources is another way to
think of data standards. Without data standards and data quality,
the future of interoperability is bleak. Data fields and the
content of those fields need to be standardized.
Standards development organizations (SDOs) address a variety
of aspects of health information and informatics. For
example, the American Society for Testing and Materials (AST
M) and Health Level Seven (HL7) target clinical data
standards. Insurance and remittance standards are a focus of the
Accredited Standards Committee (ASC) X12. Standards to
transmit diagnostic images are developed through Digital Imagi
ng and Communications in Medicine (DICOM). The
National Council for Prescription Drug Programs (NCPDP) repr
esents pharmacy messages.
The Institute of Electrical and Electronics Engineers (IEEE), H
L7, ASTM, and others develop data models and
frameworks. See the table on page 65 for a breakdown of regula
tory agencies responsible for working with the American
National Standards Institute (ANSI) to drive data standards to a
chieve interoperability.
The AHIMA Leadership Model states that HIM professionals sh
ould serve as the leaders in healthcare organizations and in
their professional community for ensuring that data content stan
dards are identified, understood, implemented, and managed.
As leaders, HIM professionals will need to collaborate with inte
rnal and external partners to meet interoperability and

health information exchange agreements, influence the develop
ment of standards to meet organizational needs, and
participate in the development of standards to address local and
national industry needs.
Leadership actions for HIM professionals include but are not li
mited to:
Increase knowledge and understanding of data content standards
Assess organizational readiness
Conduct a data content standards requirements analysis
Develop a local data dictionary to support enterprise-wide inter
operability
Advance the development of data content standards
Select integrated electronic systems that support data content re
quirements
Contribute to domain knowledge by participating in relevant pro
fessional association work and mentoring others
Contribute to the development and harmonization of industry an
d professional standards
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http://library.ahima.org/Doc/1/9/0/69827
Interoperability Ensures EHR Compatibility
The Office of the National Coordinator for Health IT (ONC) def
ines interoperability as ensuring that health-related

information flows seamlessly. Information needs to follow the p
atient regardless of geographic, organizational, or vendor
boundaries. Interoperability refers to the architecture or standar
ds that make it possible for diverse EHR systems to work
compatibly. The importance of interoperability goes far beyond
the confines of the EHR. Information must flow into and out
of health information exchanges—
available to the patient at the right time, at the right place, and
containing data that is
accurate and complete.
ONC provides "building blocks" to bring awareness to maintaini
ng and sustaining standard interoperability. These current
initiatives are working to standardize:
Meaning through the use of standardized healthcare vocabularie
s
Structure by leveraging standards in HL7
Transport using secure e-mail protocols
Security through National Institute of Standards and Technolog
y (NIST)-adopted encryption standards
Services through open and accessible application programming i
nterfaces (APIs)
There are many SDOs who are involved in the development and
publishing of healthcare informatics standards at national
and international levels. These standards are crucial to the captu
ring and sharing of clinical information in our electronic
health information systems.
Regulatory Agencies in Standard Development
Multiple regulatory agencies are currently responsible for worki
ng with the ANSI standard development
organization to drive data standards that help achieve interopera
bility, including those listed in the table below.

Regulatory Agency Data, Mapping, and Messaging Standards
The Centers for Medicare and
Medicaid Services (CMS)
provides a list of data resources
including standard terms and
abbreviations that promotes
naming and semantic consistency.
The "meaningful use" EHR Incentive Program was developed
to allow care providers to implement EHR technology in three
stages. Stage 1 focuses on data capture and sharing of data,
stage 2 focuses on clinical processes such as information
exchange and patient-controlled data, and stage 3 aims to focus
on improving patient outcomes. The incremental phases allow
care providers to adopt standards into their daily workflow.
The Office of the National
Coordinator for Health
Information Technology (ONC)
promotes flexible implementation
standards that are able to change
incrementally, emphasizing
usability and workflow design to
facilitate data exchange.
Meaningful use stage 2 EHR certification criteria delineates
data standards.
The Agency for Healthcare
Research and Quality (AHRQ)
promotes the development of IT
systems which identify specific
criteria.

The National Strategy for Quality Improvement in Health Care
(National Quality Strategy) is a nationwide effort to align
public and private interests to improve the quality of health and
healthcare for all Americans. Part of the Affordable Care Act,
the National Quality Strategy is guided by three aims that
provide better, more affordable care for an individual and the
community.
The National Quality Strategy (NQS) promotes "national
standards while supporting local, community, and state-level
activities that respond to local circumstances."2 The NQS also
works to align quality efforts among commercial and
government activities, and across federal agencies.
Standards Development
In order to drive interoperability, the adoption of messaging sta
ndards is primarily driven by regulation. There are also
stakeholder groups hard at work on harmonization efforts to ma
nage information in standardized processes to enable data
sharing. A consensus process gathers interested individuals fro
m industry and consumer groups, specialty domains,
agencies, professional organizations, and vendors to develop a c
oncept and express it in a recommended course of action or
standard. Then, a document is drafted to further refine the conce
pt and work through details by an interactive voting process
to assure that the completed standard has been accorded fair rev
iew prior to publishing.

ASTM publishes standard test methods, specifications practices,
guides, terminologies, and classifications. ASTM E1384
and E31.25 (2013) Standard Practice for Content and Structure
of the Electronic Health Record (EHR) describes a logical
data organization and content (common data model) of an EHR.
The model is used by an organization according to the
major informational structures and content of the EHR. A patien
t's health record plays five unique roles:
1. It represents the patient's health history.
2. It provides a method for clinical communication and care pla
nning among the individual healthcare practitioners
serving the patient.
3. It serves as the legal document describing the healthcare serv
ices provided.
4. It is a source of data for clinical, health services, and outcom
es research.
5. It serves as a major resource for healthcare practitioner educa
tion.
HL7 is one organization that is developing international standar
ds for interoperability and messaging including the
Consolidated Clinical Document Architecture (C-CDA) and EH
R functional model. HL7 develops international standards,
which sometimes must be modified to meet the "meaningful use
" EHR Incentive Program or reimbursement systems criteria
unique to the United States. HL7 collaborates with the Internati
onal Organization for Standardization (ISO) for international
balloting.
ISO, the world's largest developer of voluntary standards, has m
any technical committees (TCs) that span a variety of
products and services. ISO/TC 215 Health Informatics primarily
develops voluntary standards in the field of information for
health and health information and communication technology to

promote interoperability. ISO/TC 215 includes standards for
areas such as healthcare delivery, disease prevention and wellne
ss promotion, public health and surveillance, and clinical
research related to health services.
Health informatics standards will play significant roles as electr
onic data management increases. It is important that HIM
professionals learn about informatics in order to serve as a prof
essional resource to healthcare organizations. HIM
professionals can participate in the standards development proce
ss by evaluating proposed standards and recommending
new ones. There has never been a greater need for input from th
e HIM perspective in the domain of data standards.
Areas for standardization in healthcare include health informati
on exchanges (HIE), clinical data harmonization, and
documentation.
Data Standards for Health Information Exchange
Health information exchange organizations are an important par
t of improving efficiency and reducing cost for healthcare
delivery, and global standards will make a difference in the way
healthcare professionals capture and use health information
worldwide.
4
To foster adoption of standardized language to meet the mandat
es of the meaningful use program, HL7 is offering free

access to their standards. HL7's C-CDA is a library of templates
that help facilitate exchange. While multiple record types
fall under the C-CDA, they all provide a common format to assi
st in health information exchange. This library contains the
following nine templates:
Continuity of Care Document (CCD)
Consultation Note
Diagnostic Imaging Report (DIR)
Discharge Summary
History and Physical (H&P)
Operative Note
Procedure Note
Progress Note
Unstructured Document
Each template has defined sections to harmonize the data across
systems. This standard ensures the information integrity
and reliability when sharing data across HIEs or between other
health IT systems.
The Role of Metadata in Standardization
Metadata is identified as a method to manage health information
by indexing and applying attributes to a patient's record at
the "granular" or data-element level. An emerging use of metada
ta is the processing of large amounts of data for data
analytics. Being able to distill large amounts of data for specific
data points will allow the metadata to be used to develop
and improve quality care. Metadata will be critical for leveragin
g the volumes, velocity, and variety of healthcare data now
available due to the increasing use of clinical information syste
ms such as EHRs.
Though metadata will be critical for maintaining and preserving
the healthcare record, there are currently no standards for

the metadata schema. The proposed HL7 EHR-S RM-ES Functio
nal profile will require the capture and retention of
authors, data creation time stamps, modification, view, and dele
tion. HL7 standards are also not mandated at this time, but
using the conformance criteria will benefit health information m
anagement professionals who are involved with the RFP
process or are assessing an EHR system.
The schema varies by organization and within jurisdictions acco
rding to business needs. HIM professionals need to direct
their organizations to consider specific business needs and the r
egulatory environment when making decisions about the
maintenance and management of metadata. Understanding and
managing metadata is not the sole responsibility of
information technology (IT) professionals. HIM professionals s
hould collaborate with IT to develop processes and
procedures to ensure that metadata is managed effectively withi
n their organizations.
Metadata captures information such as the date and time that an
entry was made in the health record, who accessed the
record and when, what changes have been made to the record an
d by whom, and the identity of staff who document sections
of the record when this information is not collected by an authe
ntication or signature, such as portions of a template that are
completed by nursing or other allied healthcare staff. Metadata i
s an important tool that can be used to follow up on
documentation or compliance issues, facilitate response to reque
sts for an accounting of accesses of the medical record, or
to meet internal or external reporting or analytics requirements.
Clinical Data Standards Harmonization
Semantic interoperability is the ability of computer systems to i
nterchange data and to interpret and use the data according
to its meaning, rather than just its surface form. Problems arise

when one term has multiple meanings or when two or more
terms refer to the same concept but are not easily recognized as
synonyms. Many multi-stakeholder workgroups are in
existence today to address semantic interoperability. Examples i
nclude HL7, ISO, and the International Health Terminology
Standards Development Organisation (IHTSDO)—
the organization that maintains SNOMED CT.
Harmonizing disparate information systems requires data transla
tion and mapping, as well as document and messaging
standards with a regulatory framework that promotes their use.
HIM professionals understand where data is created and
distributed; this knowledge can be utilized to ensure harmonizat
ion between systems. There are multiple data models as
they relate to health information exchange such as centralized, d
ecentralized, and federated models. The type of model
selected will determine how and where information will be colle
cted and stored.
A centralized model collects data from local sources and stores
the data in a central repository. A decentralized data model,
also called a federated model, gives an organization control of t
he healthcare record, providing a quick and easy way to
distribute data-sharing across regions. The hybrid model is a co
mbination of the previous two models.
Along with developing standards for meaningful use interoperab
ility, it is important to exchange information with standalone
registry systems. When developing these standards, these syste

ms should be considered in the forefront to eliminate manual
data collection into disparate systems. Without standards there
will be unstable and inconsistent data collection resulting in
the inability to compare and improve outcomes.
When developing standards one also needs to consider the abilit
y to connect clinical outcomes with billing data to help
determine the value of healthcare provided. The value of health
care is the quality over the cost. Every system has its own
way of representing data. For example, relational databases hav
e their own schema for defining tables and fields.
Ontologies are one method of managing data and providing a me
chanism for disparate systems to communicate. Although
this is not a new term, it will be one that HIM professionals will
hear in discussions related to interoperability and data
standards. An ontology viewed with a data standards lens is a m
odel of knowledge that serves as a semantic translator that
is able to reconcile metadata standards, XML dialects, and datab
ase access methods.
Data Standards and Documentation of Health Services
Employing data standards in health services documentation furt
her entails consistent, accurate, and reproducible capture of
clinical concepts using standardized terminology to describe dis
eases and procedures. This supports an environment
conducive to the assessment of patient management, outcomes
measures for quality and performance improvement, and
clinical research. Current initiatives to measure quality and perf
ormance through data include the Joint Commission Core
Measures, CMS' Present on Admission Indicator Reporting, CM
S' Clinical Quality Measures, and the National Committee
for Quality Assurance Healthcare Effectiveness Data and Inform
ation Set (HEDIS).
Documentation describes the methods and activities of collectin

g, coding, ordering, storing, and retrieving information to
fulfill future tasks.
Whether the information is collected, stored, and read on paper
or discrete data elements are recorded,
electronically stored, and then displayed as traditional documen
ts on a computer monitor, data content requirements remain
the same. The appropriate recording of data for patient records i
s required for continuous treatment of patients. The quality
and safety of medical decision making during the course of prov
iding a health service relies on the timeliness and accuracy
of the information available.
Observations, assessments, and plans made during the care of in
dividual patients are all important elements of
documentation.
There are a variety of messaging and data content standards rel
ated to clinical documentation capture,
storage, retrieval, and use. Data structure and content standards
create the framework for an optimal health record and
effective information exchange between healthcare providers. A
data content standard often leverages a terminology
standard to simplify and unify the data presentation.
With increasing focus on adoption of certified EHRs, along with
financial incentives to demonstrate meaningful use and
improve healthcare quality, there is increased urgency to develo
p definitions and standards. Specified terminology standards
definitions and classifications of individual terms, coupled with
content standards for uniform capture and collection, are
essential framing structures to describe clinical concepts—
such as the use of SNOMED CT for problem list identification.
Effectively sending data back and forth between organizations i
s accomplished with messaging standards.
Commonly used guidelines for standards in EHR systems includ
e:

Continuity of Care Record/Document
National Council for Prescription Drug Programs (NCPDP)
Digital Imaging and Communications in Medicine (DICOM)
SNOMED CT
Logical Observation Identifiers Names and Codes (LOINC)
ICD-9-CM
ICD-10-CM/PCS
RxNorm
5
6
7
Current Procedural Terminology (CPT)
The National Library of Medicine's Unified Medical Language S
ystem links more than 100 terminologies available for a
variety of use cases in healthcare.
Describing clinical concepts in a standardized format allows for
meaningful performance monitoring and outcomes
measurement. In addition it supports consistent, evidence-based
care through clinical decision support. The National Quality
Forum's Quality Data Model (QDM) provides the potential for
more precisely defined, universally adopted electronic
quality measures to automate measurement and compare and im
prove quality using electronic health information.

Recommendations for Promoting Standards
Priorities and emphasis on health informatics standards will set
expectations for the healthcare industry. HIM professionals
are in a position to advocate the application of standards and ed
ucate their colleagues. Standards contribute to the
longitudinal view of health information within and among syste
ms by calling for unified expectations about how data is
defined, stored, and transferred to meet the users' needs. The ab
ility to use this information to drive decisions through
business intelligence is an emerging role for HIM professionals.
HIM professionals can increase their knowledge and serve
as a professional resource for their organization by:
Building knowledge in health informatics standards. Remain we
ll informed on standards that impact patient data
and health information business processes. At a minimum, under
stand the relationship and major topic areas. Refer to
Appendix A for a variety of standards development organization
s and their websites. Refer to Appendix B for
additional reading materials.
Investigate current data systems. Verify HIM business processes
that connect to these functions. Determine
whether data definition or format changes need to be planned in
preparation for regulatory implementation. See that
related HIM processes are updated as necessary.
Access information on existing healthcare standards. Review cu
rrent standards and how they generally fit into the
health information systems environment in healthcare organizati
ons.
Determine if the current healthcare standards are used in your o
rganization. Note that although standards may
be adopted in your organization, the manner in which the standa
rds are used can be highly customized so those
vendors can accommodate product variability, among other reas

ons. Investigate how your organization uses message
standards.
Form or join a quality and data analytics team in your organizati
on. Become familiar with the types of
information being requested and where it fits into the standards
realm. Create a matrix to track what types of data are
transmitted, how it is transmitted, and what standards are used.
Keep pace with the healthcare industry's standards development.
Professionally endorse these efforts.
Join a standards development organization. HIM professionals'
contribution to this work is essential to ensure
comprehensive attention to health information business processe
s. Membership fees are often nominal and progress
can be tracked through the standards website, organization's Wi
ki page, or through personal participation in
development sessions.
Appendices
Appendix A: Data Standards Resource
Working independently, standards development organizations (S
DOs), associations, government agencies, and
nongovernmental organizations have developed an array of data
standards that address multiple areas in healthcare.
Different standards are required to implement electronic health
records (EHRs) and facilitate interoperability.
Standards are developed both nationally and internationally. Th
e American National Standards Institute (ANSI) coordinates
the development and use of standards within the United States a
nd represents the needs and views of US stakeholders in
standardization forums around the globe. ANSI facilitates the de
velopment of American National Standards by accrediting
the procedures of standards development organizations. ANSI a
ccreditation signifies that the procedures used by the SDO

meet ANSI's essential requirements for openness, balance, cons
ensus, and due process.
The tables in this Practice Brief appendix outlines a sample of s
ome of the common standards used today. Placing a
8
standard in one category is difficult because various standards c
an be classified in more than one way, so in some instances,
standards are repeated in multiple categories.
Structure and Content Standards
Standards establish definitions for data elements in an EHR syst
em. They specify the type of data to be collected in each
data field and the attributes and values of each field, all of whic
h are captured in data dictionaries.
Resource Description Source
ASTM
Continuity of
Care Record
(CCR)
Designation: E
2369-05
Data content and document standard for relaying a patient's core

data set upon
transfer to support continuity of care.
ASTM
HL7 Standards:
Primary
Standards
Most frequently used HL7 standards HL7
Health Level
Seven (HL7)
Clinical
Document
Architecture
(CDA)
Release 2.0
CDA Release 2.0 provides an exchange model for clinical docu
ments such as
discharge summaries and progress notes. By leveraging the use
of XML, the HL7
Reference Information Models (RIMs), and coded vocabularies,
the CDA makes
documents both machine-readable (so they are easily parsed and
processed
electronically) and human-readable (so they can be easily retrie
ved and used by the
people who need them). CDA documents can be displayed using
XML-aware Web
browsers or wireless applications such as cell phones.
HL7
HL7 Continuity

of Care
Document
(CCD)
The CCD was developed as a collaborative effort between AST
M and HL7. It is
intended as an alternate implementation of the ASTM Continuit
y of Care Record for
those institutions or organizations implementing the HL7 Clinic
al Document
Architecture.
HL7
HL7
Communication
Standard,
Version 3
Version 3 of the HL7 Communication Standard uses a methodol
ogy based on a
reference information model (i.e., data). HL7's primary goal for
Version 3 is to offer
a standard that is definite and testable and provides the ability t
o certify vendor
conformance.
HL7
HL7 Version 2
Product Suite
Messaging standard for electronic data exchange. HL7
HL7 Version 3
Product Suite

Messaging standard driven by messages and electronic documen
ts in XML syntax. HL7
National
Data dictionary and data content standards for pharmacy data, d
eveloped by NCPDP
http://www.astm.org/
http://www.hl7.org/implement/standards/product_section.cfm?s
ection=1
http://www.hl7.org/Library/standards.cfm
http://www.hl7.org/implement/standards/product_brief.cfm?pro
duct_id=6
http://www.ncpdp.org/members/stds-
102508/data_dictionary_201003.pdf
Council for
Prescription
Drug Programs
(NCPDP) Data
Dictionary
NCPDP.
Functional EHR Standards
Standards that define the components an EHR needs to support t

he functions for which it was designed.
HL7 Standards: EHR
Profiles
These standards provide functional models and profiles that ena
ble the
constructs for management of electronic health records.
HL7
Public Health Data
Standards Consortium
(PHDCS ) Functional
Standards
A reference list of functions that may be present in an EHR syst
em. The
function list is described from a user perspective with the intent
to enable
consistent expression of system functionality. Through the creat
ion of
functional profiles, this model enables a standardized descriptio
n and
common understanding of functions sought or available in a giv
en setting
(i.e., intensive care, cardiology, office practice in one country,
or primary
care in another country).
PHDSC
Technical/Interoperability Standards

Standards that complement other types of standards and make in
teroperability possible by providing the roles, or protocols,
of how these data are actually transmitted from one computer sy
stem to another.
Digital Imaging
and
Communications
in Medicine
(DICOM)
Messaging standard for digital images. DICOM is produced and
managed by the DICOM
standards committee, which consists of vendors, user organizati
ons, government agencies,
and trade associations.
DICOM
HL7 Arden
Syntax for
Medical Logic
Systems (v2.0-
v2.9)
This specification addresses the sharing of computerized health
knowledge bases among
personnel, information systems, and institutions. The scope has
been limited to those
knowledge bases that can be represented as a set of discrete mo
dules. Each module,
referred to as a Medical Logic Module (MLM), contains sufficie
nt knowledge to make a
single decision.

HL7
HL7 Clinical
Document
Architecture
(CDA) Release
CDA Release 2.0 provides an exchange model for clinical docu
ments such as discharge
summaries and progress notes. By leveraging the use of XML, H
L7 Reference Information
Models (RIMs), and coded vocabularies, the CDA makes docum
ents both machine-readable
(so they are easily parsed and processed electronically) and hum
an-readable (so they can be
easily retrieved and used by the people who need them). CDA d
ocuments can be displayed
HL7
http://www.hl7.org/implement/standards/product_section.cfm?s
ection=4
http://www.phdsc.org/standards/health-
information/F_Standards.asp
http://medical.nema.org/dicom/
http://www.hl7.org/search/index.cfm?criteria=arden+syntax
2.0

easily retrieved and used by the people who need them). CDA d
ocuments can be displayed
using XML-aware Web browsers or wireless applications such a
s cell phones.
HL7 Continuity
of Care
Document
(CCD)
The CCD was developed as a collaborative effort between AST
M and HL7. It is intended
as an alternate implementation of the ASTM Continuity of Care
Record for those institutions
or organizations implementing the HL7 Clinical Document Arch
itecture.
HL7
HL7 Clinical
Context
Management
(CCOW)
The CCOW standards specify technology-neutral architectures,
component interfaces, and
data definitions as well as an array of interoperable technology-
specific mappings of these
architectures, interfaces, and definitions.
HL7
HL7 Version 3
Communication
Standard

Version 3 uses a methodology based on a reference information
model (i.e., data). HL7's
primary goal for Version 3 is to offer a standard that is definite
and testable and provides the
ability to certify vendors' conformance.
HL7
HL7 Version 2.5
Communication
Standard
HL7 Version 2.5 introduced a number of new events, segments,
and messages, as well as an
expanded chapter on control.
HL7
HL7 Version 2.4
Communication
Standard
HL7 Version 2.4 introduces conformance query profiles in chapt
er 5 and adds messages for
laboratory automation, application management, and personnel
management.
HL7
HL7 Version
2.3.1
Communication
Standard
HL7 Version 2.3.1 includes an updated timing/quantity data typ
e to manage order

occurrences, updates to facilitate public health surveillance repo
rting, segments and data
types to accommodate international paradigms for reporting na
mes and pharmacy orders,
and the addition of a new field to satisfy the CMS Medical Nece
ssity requirements for
outpatient services and federal requirements for Level 2 modifie
rs.
HL7
IEEE 1073 Point
of Care Medical
Device
Communication
A family of medical device communications standards which all
ows hospitals and other
healthcare providers to achieve plug-and-play interoperability b
etween medical
instrumentation and computerized healthcare information syste
ms, especially in a manner
that is compatible with the acute care environment.
IEEE
NCPDP Batch
Transaction
Standard
The NCPDP Batch Transaction Format provides practical guidel
ines and ensures consistent
implementation throughout the industry of a file submission sta
ndard to be used between
pharmacies and processors, or pharmacies, switches, and proces
sors.

NCPDP
NCPDP Billing
Unit Standard
NCPDP has
many standards,
should we list
them
Due to the number of processors, fiscal intermediaries, plan ad
ministrators, and Medicaid
programs, the NCPDP Billing Unit Standard was created to pro
mote a "common billing unit
language" for the submission of prescription claims.
NCPDP
http://www.ieee1073.org/
http://www.ncpdp.org/pdf/CMSPartDSupplementalInformationR
eporting(NTransaction)BatchStandard.pdf
http://www.ncpdp.org/standards-info.aspx
NCPDP

Formulary and
Benefit
Standard
This NCPDP Formulary and Benefit Standard provides a standar
d means for pharmacy
benefit payers (including health plans and pharmacy benefit ma
nagers) to communicate
formulary and benefit information to prescribers via technology
vendor systems.
NCPDP
S&I Framework
A collaborative of public and private sectors focusing on tools,
services, and guidance of
health information exchange.
S&I
Framework
Vocabulary, Terminology, and Classification Systems
Systems that facilitate the organization, storage, and retrieval of
healthcare data.
Standards Development Organizations
Private or government organizations involved in the developme
nt of healthcare informatics standards at a national or
international level.
AIIM
AIIM is an ANSI (American National Standards Institute) accre

dited standards development
organization. AIIM also holds the Secretariat for the ISO (Inter
national Organization for
Standardization) committee focused on information management
compliance issues, TC171.
AIIM
Accredited
Standards
Committee (ASC)
X12
ASC X12 is a designated committee under the Designated Stand
ard Maintenance
Organization (DSMO), which develops uniform standards for cr
oss-industry exchange of
business transactions through electronic data, interchange (EDI)
standards. ASC X12 is an
ANSI-accredited standards development organization.
ASC
X12
American Dental
Association
(ADA)
The ADA is an ANSI-accredited standards developing organizat
ion that develops dental
standards that promote safe and effective oral healthcare.
ADA
ASTM
International

Formerly the American Society for Testing and Materials, AST
M International is an ANSI-
accredited standards development organization that develops sta
ndards for healthcare data
security, standard record content, and protocols for exchange of
laboratory data.
ASTM
European
Committee for
Standardization
(CEN)
CEN contributes to the objectives of the European Union and Eu
ropean Economic Area with
voluntary technical standards that promote free trade, the safety
of workers and consumers,
interoperability of networks, environmental protection, exploitat
ion of research and
development programs, and public procurement.
CEN
Clinical and
Laboratory
Standards
A global nonprofit standards development organization that pro
motes the development and use
of voluntary consensus standards and guidelines within the healt
hcare community. Its core
business is the development of globally applicable voluntary co
nsensus documents for

CLSI
http://www.ncpdp.org/standards-info.aspx
http://www.siframework.org/whatis.html
http://www.aiim.org/
http://www.x12.org/
http://www.ada.org/
http://www.astm.org/
http://www.cenorm.be/cenorm/index.htm
http://www.clsi.org/
Institute (CLSI) healthcare testing.
Clinical Data
Interchange
Standards
Consortium
(CDISC)
CDISC is an open, multidisciplinary nonprofit organization that
has established worldwide
industry standards to support the electronic acquisition, exchang
e, submission and archiving of
clinical trials data and metadata for medical and biopharmaceuti
cal product development.
CDISC
Designated
Standard
Maintenance

Organization
(DSMO)
The DSMO was established in the final HIPAA rule and is charg
ed with maintaining the
standards for electronic transactions, developing or modifying a
n adopted standard.
DSMO
Health Industry
Business
Communications
Council (HIBCC)
HIBCC is an industry-sponsored and supported nonprofit organi
zation. As an ANSI-
accredited organization, its primary function is to facilitate elec
tronic communications by
developing standards for information exchange among healthcar
e trading partners.
HIBCC
Health Level 7
(HL7)
An ANSI-accredited standards development organization that de
velops messaging, data
content, and document standards to support the exchange of clin
ical information.
HL7
Institute of
Electrical and

Electronic
Engineers (IEEE)
A national organization that develops standards for hospital syst
em interface transactions,
including links between critical care bedside instruments and cli
nical information systems.
IEEE
International
Organization for
Standardization
(ISO)
ISO is a nongovernmental organization and network of national
standards institutes from 157
countries.
ISO
National Council
for Prescription
Drug Programs
(NCPDP)
A designated committee under the Designated Standard Mainten
ance Organization (DSMO)
that specializes in developing standards for exchanging prescrip
tion and payment information.
NCPDP
National
Information
Standards

Organization
(NISO)
An ANSI-accredited nonprofit association that identifies, develo
ps, maintains, and publishes
technical standards to manage information. NISO standards addr
ess areas of retrieval, re-
purposing, storage, metadata, and preservation.
NISO
National Uniform
Billing Committee
(NUBC)
A designated committee under the Designated Standard Mainten
ance Organization (DSMO)
that is responsible for identifying data elements and designing t
he CMS-1500.
NUBC
http://www.cdisc.org/
http://www.hipaa-dsmo.org/
http://www.hibcc.org/
http://www.hl7.org/
http://www.ieee.org/
http://www.iso.org/iso/home
http://www.ncpdp.org/
http://www.niso.org/
http://www.nubc.org/

National Uniform
Claim Committee
(NUCC)
The national group that replaces the Uniform Claim Form Task
Force in 1995 and developed a
standard data set to be used in the transmission of non-institutio
nal provider claims to and
from third-party payers.
NUCC
Coordinators and Promoters of Standards Development
AHIMA
AHIMA is the premier association of HIM professionals. AHIM
A's 67,000 members
are dedicated to the effective management of personal health inf
ormation needed to
deliver quality healthcare to the public. Founded in 1928 to imp
rove the quality of
medical records, AHIMA is committed to advancing the HIM pr
ofession in an
increasingly electronic and global environment through leadersh
ip in advocacy,
education, certification, and lifelong learning.
AHIMA
American
National
Standards
Institute

(ANSI)
ANSI coordinates the development and use of voluntary consens
us standards in the
United States and represents the needs and views of US stakehol
ders in
standardization forums around the globe. It oversees the creatio
n, promulgation and
use of thousands of norms and guidelines that directly affect bu
sinesses in nearly
every sector. ANSI is also actively engaged in accrediting progr
ams that assess
conformance to standards including globally recognized cross-s
ector programs such as
the ISO 9000 (quality) and ISO 14000 (environmental) manage
ment systems.
ANSI
Healthcare
Information
and
Management
Systems
Society
(HIMSS)
A membership organization exclusively focused on providing gl
obal leadership for the
optimal use of healthcare information technology and manageme
nt systems for the
betterment of healthcare.
HIMSS
Workgroup

for
Electronic
Data
Interchange
(WEDI)
A subgroup of Accreditation Standards Committee X12 that has
been involved in
developing electronic data interchange standards for billing tran
sactions.
WEDI
Data Standards Initiatives and Resources
National e-Health
Collaborative
(NeHC)
A federally chartered commission that provides input and recom
mendations to
HHS on how to make health records digital and interoperable an
d ensure that
the privacy and security of those records are protected in a smo
oth, market-led
way. The mission of the National e-Health Collaborative (NeHC
) is to help
NeHC
http://www.nucc.org/
http://www.ahima.org/
http://www.ansi.org/
http://www.himss.org/

http://www.wedi.org/
http://www.nationalehealth.org/
address barriers that could thwart the nation's progress toward i
nteroperability.
Certification
Commission for
Healthcare
Information
Technology
(CCHIT)
CCHIT is an independent, voluntary, private-sector initiative or
ganized to
accelerate the adoption of robust, interoperable healthcare infor
mation
technology throughout the United States by creating an efficient
, credible,
sustainable mechanism for the certification of healthcare IT pro
ducts.
CCHIT
Health IT Policy
Committee
The Health IT Policy Committee will make recommendations to
the National
Coordinator for Health IT on a policy framework for the develo
pment and

adoption of a nationwide health information infrastructure, incl
uding standards
for the exchange of patient medical information.
HIT
Policy
Committee
Health IT
Standards
Committee
The Health IT Standards Committee is charged with making rec
ommendations
to the National Coordinator for Health IT on standards, impleme
ntation
specifications, and certification criteria for the electronic excha
nge and use of
health information. Initially, the Health IT Standards Committee
will focus on
the policies developed by the Health IT Policy Committee's initi
al eight areas.
HIT
Standards
Committee
Public Health
Data Standards
Consortium
(PHDSC)
The Public Health Data Standards Consortium (The Consortium)
is a national
nonprofit member-based partnership of federal, state, and local
health

agencies; national and local professional associations; and publi
c and private
sector organizations and individuals. Its goal is to empower the
healthcare and
public health communities with health information technology s
tandards to
improve individual and community health.
PHDSC
National Institute
on Standards and
Technology(NIST)
An agency of the Department of Commerce that creates many of
the federal
government's security standards, which are mandated for use in
government
agencies and often by their contractors.
NIST
National Resource
for Global
Standards
A search engine that provides users with standards-related infor
mation from a
wide range of developers, including organizations accredited by
the American
National Standards Institute (ANSI), other US private sector sta
ndards bodies,
government agencies, and international organizations.
NSSN

Office of the
National
Coordinator for
Health
Information
Technology
(ONC)
ONC is the principal federal entity charged with coordination of
nationwide
efforts to implement and use the most advanced health informati
on technology
and the electronic exchange of health information. The position
of National
Coordinator was created in 2004, through an Executive Order, a
nd
legislatively mandated in the Health Information Technology fo
r Economic
and Clinical Health Act (HITECH Act) of 2009. The Office of t
he National
Coordinator for Health Information Technology provides leader
ship for the
development and nationwide implementation of an interoperable
health
information technology infrastructure to improve the quality an
d efficiency of
healthcare and the ability of consumers to manage their care and
safety.
ONC
Public Health
The Public Health Information Network (PHIN) is CDC's vision
for PHIN
http://www.cchit.org/

http://www.healthit.gov/policy-researchers-
implementers/health-it-policy-committee
implementers/health-it-standards-committee
http://www.phdsc.org/
http://www.nist.gov/
http://www.nssn.org/
http://www.healthit.gov/
http://www.cdc.gov/PHIN/
Information
Network (PHIN)
advancing fully capable and interoperable information systems i
n the many
organizations that participate in public health. PHIN is a nation
al initiative to
implement a multi-organizational business and technical archite
cture for
public health information systems.
Standards.gov
Maintained and operated by the National Institute of Standards
and
Technology (NIST), Standards.gov supports the requirements of
the National
Technology Transfer and Advancement Act (NTTAA), which be
came law in
March 1996. The NTTAA directs federal agencies with respect t
o their use of
private sector standards and conformity assessment practices. T

he objective is
for federal agencies to adopt private sector standards, wherever
possible, in
lieu of creating proprietary, non-consensus standards.
NIST
Unified Medical
Language System
(UMLS)
A multipurpose resource that includes concepts and terms from
many different
source vocabularies developed.
UMLS
United States
Health
Information
Knowledgebase
(USHIK)
USHIK is a publicly accessible registry and repository of health
care-related
data, metadata, and standards. USHIK is funded and directed by
the Agency
for Healthcare Research and Quality (AHRQ) with management
support in
partnership with the Centers for Medicare & Medicaid Services
(CMS).
USHIK
Web Ontology
Language (OWL)

A language designed for use by software applications that proce
ss the content
of information instead of just presenting information to humans.
There are
three sublanguages currently available: OWL Lite, OWL DL, an
d OWL Full.
OWL
Alternative Billing
Concepts (ABC)
Codes
ABC Codes contain more than 4,000 codes that describe what is
said,
done, ordered, prescribed, or distributed by providers of alternat
ive
medicine. Disciplines covered by this system include acupunctu
re, holistic
medicine, massage therapy, homeopathy, naturopathy, ayurvedic
medicine,
chiropractors, and midwifery.
ABC
Coders
Clinical Care
Classification (CCC)
System
A classification system consisting of two interrelated taxonomie
s: the

CCC of Nursing Diagnoses and Outcomes, and the CCC of Nurs
ing
Interventions and Actions. Both taxonomies are classified by ca
re
components, or clusters of elements that represent behavioral, f
unctional,
physiological, or psychological care patterns.
CCC
System
Current Dental
Terminology (CDT)
CDT is a coding system developed to report services performed
by the
dental profession. CDT was formally called the Uniform Code o
n Dental
Procedures and Nomenclature.
CDT
http://library.ahima.org/PB/Standards.gov
http://www.standards.gov/
http://www.nist.gov/standardsgov/
http://www.nlm.nih.gov/research/umls
http://www.ushik.org/
http://www.w3.org/TR/owl-features/
http://www.nlm.nih.gov/research/umls/sourcereleasedocs/curren
t/ALT/
http://www.sabacare.com/
http://www.ada.org/3827.aspx

Current Procedural
Terminology (CPT)
CPT is a comprehensive list of descriptive terms and codes publ
ished by
the American Medical Association (AMA) and used for reportin
g
diagnostic and therapeutic procedures and other medical service
s
performed by physicians.
CPT
Diagnostic and
Statistical Manual of
Mental Disorders,
Fifth Edition (DSM-
5)
The DSM-5 is a nomenclature to standardize the diagnostic proc
ess for
patients with psychiatric disorders.
DSM-5
Global Medical
Device
Nomenclature
(GMDN)
The GMDN is a collection of internationally recognized terms u
sed to
describe and catalog medical devices—
in particular products used in the

diagnosis, prevention, monitoring, treatment, or alleviation of d
isease or
injury in humans.
GMDN
Healthcare Common
Procedure Coding
System (HCPCS)
Code Set Level I
Level I of the HCPCS is comprised of CPT codes that are used p
rimarily
to identify medical services and procedures furnished by physici
ans and
other healthcare professionals. These healthcare professionals u
se the
CPT to identify services and procedures for which they bill publ
ic or
private health insurance programs. Level I of the HCPCS, the C
PT codes,
does not include codes needed to separately report medical item
s or
services that are regularly billed by suppliers other than physici
ans.
HCPCS
Healthcare Common
Procedure Coding
System (HCPCS)
Code Set Level II
Level II of the HCPCS is a standardized coding system that is u
sed
primarily to identify products, supplies, and services not includ

ed in the
CPT codes, such as ambulance services and durable medical equ
ipment,
prosthetics, orthotics, and supplies (DMEPOS) when used outsi
de a
physician's office.
HCPCS
International
Classification of
Diseases for
Oncology (ICD-O)
The ICD-O is the standard tool for coding diagnoses of neoplas
ms in
tumor and cancer registrars and in pathology laboratories. ICD-
O is a dual
classification with coding systems for both topography and mor
phology.
The topography code describes the site of origin of the neoplas
m and uses
the same three-character and four-character categories as in the
neoplasm
section of chapter II, ICD-10.
ICD-O
International
Classification of
Diseases, Ninth
Revision, Clinical
Modification (ICD-9-
CM)
Classification system used in the United States to code and clas

sify
diagnoses from inpatient and outpatient records and to code inp
atient
procedures. ICD-9-CM is managed by the National Center for H
ealth
Statistics.
ICD-9-CM
International
Classification of
Functioning,
Disability and Health
(ICF)
The ICF is a health and health-related classification system that
reports
body functions and structures, activities, and participation.
ICF
http://www.ada.org/3827.aspx
http://www.dsm5.org/Pages/Default.aspx
http://www.gmdnagency.com/Info.aspx?pageid=2
http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/inde
x.html?redirect=/medhcpcsgeninfo/
http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/inde
x.html?redirect=/medhcpcsgeninfo/
http://www.who.int/classifications/icd/adaptations/oncology/en/
http://www.cdc.gov/nchs/icd9.htm
http://www3.who.int/icf/icftemplate.cfm?myurl=homepage.html
&mytitle=Home%20Page

International
Classification of
Primary Care,
Second edition
(ICPC-2)
ICPC is a reliable classification system for primary care physici
ans that
enable the labeling of the most prevalent conditions that exist in
the
community as well as symptoms and complaints.
ICPC-2
International
Statistical
Classification of
Diseases and
Related Health
Problems, Tenth
Revision (ICD-10)
The ICD-10 version of the disease classification system was dev
eloped by
the World Health Organization and is used to report morbidity a
nd
mortality information worldwide. Effective with deaths occurrin
g in 1999,
the US replaced ICD-9 with ICD-10 for mortality report.
ICD-10
International
Statistical

Classification of
Diseases and
Related Health
Problems, Tenth
Revision, Clinical
Modification (ICD-
10-CM)
ICD-10-CM is the future US coding classification system for he
althcare
professionals and institutions to report morbidity and mortality
data.
ICD-10-
CM
International
Statistical
Classification of
Diseases and
Related Health
Problems, Tenth
Revision, Procedure
Coding System
(ICD-10-PCS)
ICD-10-PCS is the future US coding classification for institutio
ns to report
procedure information.
ICD-10-
PCS
Logical Observation
Identifiers, Names
and Codes (LOINC)

The LOINC coding system electronically exchanges laboratory a
nd
clinical information.
LOINC
MEDCIN
MEDCIN is a terminology and presentation engine. It includes
more than
250,000 clinical data elements encompassing symptoms, history
, physical
examination, tests, diagnoses, and therapy.
MEDCIN
Medical Dictionary
for Regulatory
Activities
(MedDRA)
MedDRA is a global standard medical terminology. It is expecte
d to
supersede or replace terminologies currently in use with the me
dical
product development process.
MedDRA
National Drug Code
NDC is a coding system for pharmacies to report services, suppl
ies, drugs, NDC
http://www.who.int/classifications/icd/adaptations/icpc2/en/
http://www.who.int/classifications/icd/en/
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

http://www.cms.gov/Medicare/Coding/ICD10/index.html
http://loinc.org/
http://www.nlm.nih.gov/research/umls/sourcereleasedocs/curren
t/MEDCIN/
http://www.meddra.org/
http://www.accessdata.fda.gov/scripts/cder/ndc/default.cfm
(NDC) and biologic information.
North American
Nursing Diagnosis
Association
(NANDA)
International
Taxonomy II
Organization of the NANDA-International nursing diagnoses ha
s evolved
from an alphabetical listing in the mid-1980s to a conceptual sy
stem that
guides the classification of nursing diagnoses in taxonomy.
NANDA
Nursing Interventions
Classification (NIC)
NIC is a comprehensive, research-based, standardized classifica
tion of
interventions that nurses perform.

NIC
Nursing Outcomes
Classification (NOC)
NOC is a comprehensive, standardized classification of patient/
client
outcomes developed to evaluate the effects of nursing interventi
ons.
NOC
Omaha System
The Omaha System is a research-based, comprehensive taxonom
y
designed to generate meaningful data following usual or routine
documentation of client care.
Omaha
System
RxNorm
RxNorm is a clinical drug nomenclature that provides standard
names for
clinical drugs (active ingredient, strength, and dose form) and f
or dose
forms as administered.
RxNorm
Systematized
Nomenclature of
Dentistry
(SNODENT)
SNODENT is a systematized nomenclature of dentistry containi

ng dental
diagnoses, signs, symptoms, and complaints.
SNODENT
Systematized
Nomenclature of
Medicine Clinical
Terms (SNOMED
CT)
SNOMED CT is a comprehensive clinical terminology and infra
structure
that enables a consistent way of capturing, sharing, and aggrega
ting health
data across specialties and sites of care.
SNOMED
CT
Universal Medical
Device
Nomenclature
System (UMDNS)
UMDNS is a standard international nomenclature and coding sy
stem used
to facilitate identifying, processing, filing, storing, retrieving, tr
ansferring,
and communicating data about medical devices.
ECRI
WHO
Appendix B: Recommended Reading

AHIMA. "Assessing and Improving EHR Data Quality (Updated
)." Journal of AHIMA 84, no.2 (March 2013): 48-53
[expanded online version].
AHIMA. "Data Mapping Best Practices." Journal of AHIMA 82,
no.4 (April 2011): 46-52.
http://www.nanda.org/html/taxonomy.html
http://www.nursing.uiowa.edu/centers/cncce/nic
http://www.nursing.uiowa.edu/cncce/nursing-outcomes-
classification-overview
http://www.omahasystem.org/
http://www.nlm.nih.gov/research/umls/rxnorm/index.html
http://www.ada.org/snodent.aspx
http://www.snomed.org/
http://www.ecri.org/
http://www.who.int/medical_devices/innovation/mde_nomenclat
ure/en/index.html
AHIMA. "Data Quality Management Model (Updated)." Journal
of AHIMA 83, no.7 (July 2012): 62-67.
AHIMA HIE Practice Council. "Ensuring Data Integrity in Healt
h Information Exchange." AHIMA, 2012.
AHIMA. "Managing a Data Dictionary." Journal of AHIMA 83,
no.1 (January 2012): 48-52.
Amatayakul, Margret. Electronic Health Records: A Practical G
uide for Professionals and Organizations, ffth edition.

Chicago, IL: AHIMA, 2013.
Cook, Jane. "HIM's Expanding Role in Clinical Data Analysis a
nd Mapping." Journal of AHIMA 83, no.9 (September
2012): 54-55.
Giannangelo, Kathy. Healthcare Code Sets, Clinical Terminolog
ies, and Classification Systems, second edition. Chicago,
IL: AHIMA, 2010.
Johns, Merida, ed. Health Information Management Technology:
An Applied Approach, third edition. Chicago, IL: AHIMA,
2010.
Kuhl, Joy. "Health Story Data Standards Included in Meaningful
Use Program." November 1, 2012.
http://journal.ahima.org/?p=7481.
Taylor, Lisa Brooks. "Show Me the Data." Journal of AHIMA 8
4, no.9 (Sept 2013): 60-61.
Government Health IT. "The Top 5 roadblocks HIE face." Nove
mber 14, 2011. http://www.govhealthit.com/news/top-5-
roadblocks-hies-face.
Public Health Data Standards Consortium. "Health Information
Technology Standards: Information Exchange Standards."
http://www.phdsc.org/standards/health-information/IE_Standard
s.asp.
Standards and Interoperability Framework. S & I Framework W
ebsite. http://www.siframework.org/.
Notes
1. Public Health Data Standards Consortium. "Data Standards."

Health Information Technology Standards. 2013.
http://www.phdsc.org/standards/health-information/d_standards.
asp.
2. Agency for Healthcare Research and Quality. "Principles for t
he National Quality Strategy (NQS)."
http://www.ahrq.gov/workingforquality/nqs/principles.htm.
3. AHIMA. "AHIMA Leadership Model: Data Content Standards
." December 30, 2008.
4. ASTM International. "Standard Practice for Content and Stru
cture of the Electronic Health Record (EHR): ASTM
E1384 - 07." 2013. http://www.astm.org/Standards/E1384.htm.
5. Liener, Florian et al. Medical Data Management: A Practical
Guide. New York, NY: Springer–Verlag, 2003.
6. Ibid.
7. AHIMA. "Guidelines for Developing a Data Dictionary." Jour
nal of AHIMA 77, no. 2 (February 2006): 64A–64D.
8. US National Library of Medicine. "Fact Sheet: Unified Medic
al Language System." March 2013.
www.nlm.nih.gov/pubs/factsheets/umls.html.
References
AHIMA. "Data Quality Management Model (Updated)." Journal
of AHIMA 83, no.7 (July 2012): 62-67.
AHIMA. "HIE Management and Operational Considerations." Jo
urnal of AHIMA 82, no.5 (May 2011): 56-61.
AHIMA. "Rules for Handling and Maintaining Metadata in the
EHR." Journal of AHIMA 84, no.5 (May 2013): 50-54.
Centers for Medicare and Medicaid Services. "Meaningful Use."
August 2013. http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.h
tml.
http://journal.ahima.org/?p=7481
http://www.govhealthit.com/news/top-5-roadblocks-hies-face
information/IE_Standards.asp
http://www.siframework.org/
information/d_standards.asp
http://www.ahrq.gov/workingforquality/nqs/principles.htm
http://www.astm.org/Standards/E1384.htm
http://www.nlm.nih.gov/pubs/factsheets/umls.html
http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.h
tml
Healthcare Cost and Utilization Project. "Enhancing the Clinical
Content of Administrative Data—Present on Admission
(POA) Toolkit: Data Standards and Transmission Tools." Augus
t 12, 2011. http://hcup-
us.ahrq.gov/datainnovations/clinicaldata/tkds.jsp.
Office of the National Coordinator for Health Information Tech
nology. "Certification and EHR Incentives."
http://www.healthit.gov/policy-researchers-implementers/certifi
cation-and-ehr-incentives#standards-certification-criteria.
National Quality Forum. "Quality Data Model." http://www.qual
ityforum.org/QualityDataModel.aspx.

Prepared by
Kathy M. Johnson, RHIA
Annessa Kirby
Lesley Kadlec, MA, RHIA
Neysa I. Noreen, RHIA
Lisa Brooks Taylor, RHIA
Joy L. Updegrove, RHIA, CHC
Diana Warner, MS, RHIA, CHPS, FAHIMA
Acknowledgements
Kathy Andersen, RHIT, CCS
Cecilia Backman, MBA, RHIA, CPHQ
Marlisa Coloso, RHIA, CCS
Julie Dooling, RHIA
Katherine Downing, MA, RHIA, CHP, PMP
Diana Reed, RHIT, CCS-P
Theresa Rihanek, MHA, RHIA, CCS
Cheryll Rogers, RHIA, CDIP, CCS, CTR
Angela Rose, MHA, RHIA, CHPS, FAHIMA
Terry J. Santana-Johnson, RHIT, CDIP, CCS, CCS-P
Patrice Spath, MA, RHIT, CHTS-IM
Lori McNeil Tolley, MEd, RHIA
Original Authors
Susan Fenton, MBA, RHIA
Kathy Giannangelo, MA, RHIA, CCS
Crystal Kallem, RHIT
Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC
The information contained in this practice brief reflects the cons
ensus opinion of the professionals who developed it. It has
not been validated through scientific research.

Article citation:
AHIMA Work Group. "Data Standards, Data Quality, and Intero
perability (2013 update)"
Journal of AHIMA 84, no.11 (November 2013): 64-69 [expande
d web version].
http://hcup-us.ahrq.gov/datainnovations/clinicaldata/tkds.jsp
implementers/certification-and-ehr-incentives#standards-
certification-criteria
http://www.qualityforum.org/QualityDataModel.aspx
Copyright © 2016 by The American Health Information Manage
ment Association. All Rights Reserved.
http://library.ahima.org/copyright
BUSI 604 100 Integrated Discussion Boards 1-4 Rubric
Criteria
Levels of Achievement
Content 70%
Advanced 92-100%
Proficient 84-91%
Developing 1-83%
Not present
Part 1-- Key Term/Concept Reservation

Part 2 -- Main Thread
37 to 40 points
Major Points are supported by all of the following:
Your thread must be placed in the Discussion Board Forum text
box and adhere precisely to the following headings:
· KEY TERM and WHY YOU ARE INTERESTED IN IT
· EXPLANATION OF THE KEY TERM
· MAJOR ARTICLE SUMMARY
· DISCUSSION
· REFERENCES
34 to 36 points
Major Points are supported by most of the following:
box and adhere precisely to the following headings and format:
· DISCUSSION
· REFERENCES
1-33 points
Major Points are supported by some of the following:
box and adhere precisely to the following headings and format:
· DISCUSSION
· REFERENCES
0 points
No work submitted.

Or
Duplicate concept reservations will not earn credit under any
circumstance—this includes work submitted in a previous
course
Part 3 – Replies
28 to 30 points
A minimum of 3 substantive and comprehensive replies to other
student postings are submitted, in at least one of the following
ways:
· compare/contrast the findings of others with your research;
· compare how the findings of others relates/adds to the
concepts learned in the required readings; and/or
· share additional empirical knowledge regarding global
business -- or international experiences you may have had --
relative to the postings of others.
25 to 27 points
A minimum of 2 substantive and comprehensive replies to other
ways:
1-24 points
A minimum of 1 substantive and comprehensive reply to other
ways:

0 points
No work submitted.
Or
course
Structure 30%
Advanced 92-100%
Proficient 84-91%
Developing 1-83%
Not present
Posted in Text Box
5 points
All 3 parts of the Forum are posted in the text box.
4 points
2 parts of the Forum are posted in the text box.
1 to 3 points
1 part of the Forum is posted in the text box.
0 points
No parts of the Forum are posted in the text box.
Or
course
Grammar/Spelling
5 points
Proper spelling and grammar are used.
4 points
Between 1–2 spelling and grammar errors are present.
1 to 3 points
Between 3–4 spelling and grammar errors are present.
0 points
More than 4 spelling and grammar errors are present.

Word Count
9 to 10 points
At least 800 words are submitted for Part 2; 450 words are
submitted for Part 3.
8 points
799 to 750 words are submitted for Part 2; 449 to 400 words are
submitted for Part 3.
1 to 7 points
749 to 100 words are submitted for Part 2; 399 to 100 words
are submitted for Part 3.
0 points
Less than 100 words are submitted for Part 2; less than 100
words are submitted for Part 3.
Part 2 References are in APA format
9 to 10 points
All references are in APA format.
8 points
Most references are in APA format.
1 to 7 points
Some references are in APA format.
0 points
No references are in APA format.
Important Notes:
All parts of the DB are posted in the text box -- not as an
attachment -- before or on the due date. In the event formatting
is lost in the text box, you may also attach your Word file to the
text box as evidence of proper formatting.
BUSI 604 Discussion Board Forum 1–4 Instructions
Important Assignment Deadlines:
· Part 1 due by 11:59 p.m. (ET) on Thursday of the first of the
assigned modules/weeks.
· Part 2 due by 11:59 p.m. (ET) on Monday of the second of the
· Part 3 due by 11:59 p.m. (ET) on Sunday of the second of the

· Note: For Module Week 8, Part 3 is due by Friday, 11:59pm
EST, since that is the last day of class. No work is accepted
after the course ends.
Part 1 (no word count)
As you read the chapters assigned to each module/week, you
will find some concepts more interesting and applicable to your
personal or work situation than others. Review the key terms
listed in the assigned chapters; then, submit a preliminary
thread indicating the key term that you wish to reserve for your
thread for that module/week.
Check the discussion board area prior to submitting your
reservation to ensure no one else has chosen that key term. In
the event the key term you wish to explore is already reserved
by someone else, simply move on to another key term in your
readings. Duplicate key terms will not earn credit under any
course. Do not ask the instructor to accept a duplicate key term,
as this is not fair to those who followed these explicit
directions.
Include the exact key term you selected in your thread’s subject
line.
Submit Part 1 to the Discussion Board Forum by 11:59 p.m.
(ET) on Thursday of the first of the assigned modules/weeks.
Part 2 (800 words minimum)
After you have successfully reserved the key term that interests
you the most, research a minimum of 5 recent scholarly articles
that relate to the concept on which you wish to focus your
research. Articles must be found in reputable professional
and/or scholarly journals and/or informational venues that deal
with the content of the course (i.e., not blogs, Wikipedia,

newspapers, etc.). After reading the articles, select the 1 article
that you wish to discuss.
It is highly recommended that you use Liberty University’s
Jerry Falwell Library online resources. A librarian is available
to assist you in all matters pertaining to conducting your
research, including what constitutes a scholarly article. For
more details on what constitutes a scholarly journal (and what
does not), visit Jerry Falwell Library’s "Scholarly Journals –
What Are They?" page.
Your thread must be placed in the Discussion Board Forum
textbox (not as an attachment) and adhere precisely to the
following headings and format:
1. Key Termand Why You Are Interested in It (100 words
minimum)
After reading the textbook, specifically state why you are
interested in conducting further research on this key term (e.g.,
academic curiosity, application to a current issue related to
employment, or any other professional rationale). Include a
substantive reason, not simply a phrase.
2. Explanation of the Key Term(100 words minimum)
Provide a clear and concise overview of the essentials relevant
to understanding this key term.
3. Major Article Summary(300 words minimum)
Using your own words, provide a clear and concise summary of
the article, including the major points and conclusions.
4. Discussion
In your own words, discuss each of the following points:
a. How the cited work relates to your above explanation AND
how it relates specifically to the content of the assigned

module/week. This part of your thread provides evidence that
you have extended your understanding of this key term beyond
the textbook readings. (150 words minimum)
b. How the cited work relates to the other 4 works you
researched. This part of your thread provides evidence that you
have refined your research key term to a coherent and
specialized aspect of the key term, rather than a random
selection of works on the key term. The idea here is to prove
that you have focused your research and that all works cited are
related in some manner to each other rather than simply a
collection of the first 5 results from your Internet search. (150
words minimum)
5. References
A minimum of 5 recent scholarly articles (not textbooks,
Wikipedia, or other popular reading magazines), in current APA
format, must be included and must contain persistent links so
others may have instant access. In the event that formatting is
lost or corrupted when submitting the thread, attach the
Microsoft Word document to your thread as evidence that your
work was completed in the proper format. Access the following
URL from the Jerry Falwell Library for instructions on creating
persistent links: How to Create a Persistent Link.
(ET) on Monday of the second of the assigned modules/weeks.
Part 3 (150 words minimum, per reply)
Additionally, you will reply to a minimum of 3 other
classmates’ threads. Thus, you will have submit substantive
written responses to a minimum of 3 other classmates’ threads.
(ET) on Sunday of the second of the assigned modules/weeks.
· Note: For Module Week 8, Part 3 is due by Friday, 11:59pm
EST, since that is the last day of class. No work is accepted

after the course ends.
Performance Task: Write a Narrative
Now that you've read both points of view on nature—that of the
Transcendentalists, and that of Oates — which perspective do
you agree with?
· Create a narrative using one of the perspectives you read
about: supporting nature or going against it.
· Tell a story about an experience you had in nature that either
affected you positively or negatively.
· Compose a narrative of 500–1,000 words that discusses your
experience in nature.
· Be clear on the stance you are choosing, and what you have
learned from this experience.
· Has reading the poems and stories of the Transcendentalists
changed your perspective on nature for the better or worse?
Performance Task: Argument with Research
One of the goals of this unit is to conduct research. Now that
you have finished reading The Adventures of Huckleberry
Finn, you will be conducting and writing your own research
paper of 1,000–1,500 words on one of the topics listed below.
In addition to specific quotes and evidence from the text, you
will use outside research to support your claims. You may use
articles and information found online, in books, or
magazines, but do not use Wikipedia. All research must be
properly cited in MLA format on a final "Works Cited" page
listing all sources used. (Refer to the MLA Formatting and Style
Guide for support.)
· Examine the novel's portrayal of racism. Is the novel racist or
is it merely holding a mirror to a racist society?
Essay could examine: Huck's relationship with Jim, Pap's views
of African Americans, Twain's portrayal of Jim, Use of the "n"
word. Is Twain taking a stance against, and shining a light on,

society, showing them the absurdity of their ways? Or, is this
providing the author's own perspective on the time? Choose one
side and defend.
· Is Huck a transcendentalist, reflecting the new philosophy of
the time? Use quotes from the book, as well as research on the
transcendental philosophy, to argue for or against this claim.
· The Adventures of Huckleberry Finn was censored
immediately upon its release, and is still censored in many
schools today. Argue or support that this book deserves to be
censored, comparing it with modern censorship of books or
media. Research the reasons behind the book's censorship both
then and now, as well as other media that has been censored in
modern times, and the reasons for that censorship. Is it
justified, or does it infringe upon the First Amendment?

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