Intro to HIT

Cassandra Booe
Data Dictionary

Prior to creating the data dictionary, I would need to determine the complexity and decide
rather the use of a spreadsheet or a data management program application would be most
appropriate. I would then collect information or metadata on each element found most common
across the domains and determine the metadata to be collected. An approvals process and
documentation trail for all initial data dictionary decisions would need to be developed and make
sure that everyone is using the same version in order to maintain data integrity. I would also
make sure that there is flexibility within the dictionary in order to so that the system can
accommodate changes as a result of clinical and technical changes. In addition to this, I would
make sure that the data dictionary field values could be expanded as needed. I would need to
make sure that it follows the ISO/International Electro technical Commission (IEC) 11179
Guidelines as well as make sure to use nationally recognized standards and field definitions in
order to accommodate the many different users of the data dictionary. I would also use
geographic codes and geocoding standards that conform to the National Spatial Data
Infrastructure and Federal Geographic Data Committee. This is important so that valid street
addresses, zip codes, county, state, and country codes can be exchanged across systems and
geopolitical boundaries. Once this is all completed, I would test the system to make sure that it
conforms to the standards defined by the data dictionary and make sure to provide ongoing
training and education to staff.
One data element that could be applied to the data dictionary is patient demographic
information such as age, sex or zip code. I will use the patients age as an example. First, you
would need to come up with a naming convention such as PT_AGE. I would then define the
patients age in the data dictionary such as Age of patient calculated by using most recent

Intro to HIT
Cassandra Booe
Data Dictionary

birthday attained before or on same day as discharge. This helps to eliminate inconsistent
definitions between different users of the data dictionary. I would then choose the data type
indicating rather the entry can be alphanumeric, date, or numeric. For the patients age, the
appropriate data type would be numeric. The next step would be to choose the format allowed to
enter the patients age. Based on what I preferred I could choose a format such as Age in years
x to xxx with a field size of 3. This way the user entering in the age information could only
enter in a numeric value with no more than 3 characters for the patients age in years. Next I
would input the values to help define what values could be used for the patients age. I would use
the value Age must be >0, and <OR 124 years. The next step is choosing the source system
such as patient census; practice management and then the date first entered. The final step
would be to explain why the item is included. In this case it would be Patient age impacts the
services utilized and payer sources. All of these steps ensure that the patient age entered will be
consistent by all users.

Intro to HIT
Cassandra Booe
Data Dictionary

Resources:
AHIMA. "Managing a Data Dictionary" Journal of AHIMA 83, no.1 (January 2012): 48-52.
Retrieved from: http://library.ahima.org/doc?oid=105176#.V-sjvslsiFp
AHIMA e-HIM Work Group on EHR Data Content. "Guidelines for Developing a Data
Dictionary" Journal of AHIMA 77, no.2 (February 2006): 64A-D. Retrieved from:
http://library.ahima.org/doc?oid=106229#.V-sns8lsiFo
Sayles, N. & Gordon, L. (2016). Health Information Management Technology An Applied
Approach. AHIMA Press Publications. Chicago, IL.