Central to developing effective health information system is data quality.

Knowledge is defined by Johns (1997) as a combination of rules, relationship, ideas,

and experience.
The same data may provide different information to different users. One persons
data may be another persons information.
Case study of the common problems associated with poor medical record
documentation.
The medical record used as evidence in court, but the same problem can lead poor
quality of care, poor communication, and poor documentation.
The five major functions that are negatively affected by poor-quality documentation
(medical Record Institute, 2004) :
1. Patient safety is affected by inadequate information, illegible entries,
misinterpretations, and insufficient interoperability.
2. Public safety, a major component of public health, is diminished by inability
to collect information in a coordinated, timely manner at the provider level in
response to epidemics and the threat of terrorism.
3. Continuity patient care is adversely affected by the lack of shareable
information among patient providers.
4. Health care economics are adversely affected, with information capture and
report generation cost currently estimated to be well over $50 billion
annually.
5. Clinical research and outcomes analysis is adversely affected by a lack of
uniform information capture that is needed to facilitate the derivation of data
from routine patient care documentation.
Poor-quality data collection and reporting at the organizational level may find
diminished quality in:
1.
2.
3.
4.
5.

Patient care
Poor communication among providers and patients
Problems with documentation
Reduced revenue generation due to problems with reimbursement,
A diminished capacity in effectively evaluate outcomes or participate in
research activities.

MRI Principle of Health Care Documentation [MRI, 2004, p. 3]

1. Unique patient identification must be assured within and across healthcare

documentation system
2. Healthcare documentation must be
Accurate and consistent
Complete
Timely
Interoperable across types of documentation systems
Accessible at any time and at any place where patient care is needed
auditable
3. confidential and secure authentication and accountability must be provided
The AHIMA Data Quality Model
The AHIMA data quality characteristic can serve as the basis for establishing data
quality standards because they represent common dimensions of health care data
that should always be presen, regardless of the use of the data or resulting
information.
The common dimensions of health care data :
1. Data

accuracy.

Data

that

reflect

correct,

valid

value

are

accurate.

Typographical errors in discharge summaries and misspelled name are

example of inaccurate data.
2. Data accessibility. Data that are not available to the decision makers needing
them are of no use.
3. Data comprehensiveness. All of data required for a particular use must be
present and available to the user. Even relevant data may not be useful when
they are incomplete.
4. Data consistency. Quality data are consistent. Use of an abbreviation that has
two different meanings provides a good example of how lack of consistency
can lead to problems. For example, a nurse may use the abbreviation CPR to
mean cardiopulmonary resuscitation at one time and use it to mean
computer-based patient record at another time, leading to confusion.
5. Data currency. Many types of health care data become obsolete after a period
of time. A patients admitting diagnosis is often not the same as the diagnosis
recorded upon discharge. If a healthcare executive needs a report on the
diagnoses treated during a particular time frame, which of these two
diagnoses should be included?
6. Data definition. Clear definitions of data elements must be provided so that
both current and future data users will understand what the data mean. One

way to supply clear data definitions is to use data dictionaries. A case

described by A.M Shakir (1999) offers an excellent example of the need for
clear data definitions.
7. Data granularity. Data granularity is sometimes referred to as data atomicity.
That is, individual data elements are atomic in the sense that they cannot be
further subdivided. For example, a typical patients name should generally be
store as three data elements (last name, first name, middle name Smith
and John and Allen) not as a single data element (John Allen Smith).
Again, granularity is related to the purpose for which the data are collected.
Although it is possible to subdivide a persons birth date into separate fields
for the month, the date, and the year, this is usually not desirable. The birth
date is at its lowest practical level of granularity when used as a patient
identifier. Values for data should be defined at the correct level for their use.
8. Data precision. Precision often relates to numerical data. Precision denotes
how close to an annual size, weight, or other standard a particular
measurement is. Some health care data must be very precise. For example,
in figuring a drug dosage it is not all right to round up to the nearest gram
when the drug is to be dosed in milligrams.
9. Data relevancy. Data must be relevant to the purpose for which they are
collected. We could collect very accurate, timely data about a patients color
preferences or choice of hairdresser, but is this relevant to the care of the
patient?
10.Data timeliness. Timeliness is a critical dimension in the quality of many
types of health care data. For example, critical lab values must be available
to the health care provider in a timely manner. Producing accurate result after
the patient has been discharged may be of little or no value to the patents
care.