A Health Data Dictionary is a database that describes the organization and logical structure of the medical data found in a clinical database. It contains “metadata”—or “data about data”—that describes the content, structure, and relationships between clinical data. In short, a medical data dictionary “translates,” precisely defines, and effectively accesses the contents of the EHR.
Over three decades ago, the concept of a medical data dictionary began as a means of supporting clinical information systems and the computerized patient record. A well-designed, intelligent medical data dictionary with terminology services can enable a healthcare organization or EHR system to comply with vocabulary standards and exchange clinical data, received in all of its various formats and terminologies from diverse systems and sources. When applied in real-time to an organization’s information system infrastructure, such a dictionary can:
• Describe clinical data in all its possible forms, providing a roadmap to the content and structure of the patient database
• Support encoding of clinical data to remove ambiguities (CMVs)
• Support exchange and comparison of data between independent computer systems
• Provide structure and content for decision support across care encounters
• Enable users to effectively query and report on the database
• Support standardization of clinical data across enterprises by incorporating industry-standard controlled medical vocabularies (CMVs) as its foundation