ISO TR 12300-2014 Health informatics - Principles of mapping between terminological systems《健康信息学 术语系统之间的映射原理》.pdf

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1、 ISO 2014 Health informatics Principles of mapping between terminological systems Informatique de sant Cartographie des terminologies de classifications TECHNICAL REPORT ISO/TR 12300 First edition 2014-11-15 Reference number ISO/TR 12300:2014(E) ISO/TR 12300:2014(E)ii ISO 2014 All rights reserved CO

2、PYRIGHT PROTECTED DOCUMENT ISO 2014 All rights reserved. Unless otherwise specified, no part of this publication may be reproduced or utilized otherwise in any form or by any means, electronic or mechanical, including photocopying, or posting on the internet or an intranet, without prior written per

3、mission. Permission can be requested from either ISO at the address below or ISOs member body in the country of the requester. ISO copyright office Case postale 56 CH-1211 Geneva 20 Tel. + 41 22 749 01 11 Fax + 41 22 749 09 47 E-mail copyrightiso.org Web www.iso.org Published in Switzerland ISO/TR 1

4、2300:2014(E) ISO 2014 All rights reserved iii Contents Page Foreword v Introduction vi 1 Scope . 1 2 T erms and definitions . 1 2.1 General . 1 2.2 Terminological resources. 4 3 Symbols and abbreviations . 6 4 Summary of key issues for decision makers . 6 4.1 General . 6 4.2 Purpose of the map . 6 4

5、.3 Map use frequency . 7 4.4 Building the map . 8 4.5 Commitment and adequate resourcing . 9 4.6 Challenges in achieving automated classification assignment on the basis of a map 10 4.7 Context is crucial to map production 11 4.8 Implementing a map table .12 4.9 Decision making matrix .12 5 Principl

6、es of mapping 14 5.1 Overview .14 5.2 Terminologies vs classifications15 5.3 One-time or maintained maps 17 5.4 Business case for mapping 18 5.5 Why are maps used? 19 6 Characteristics of a quality map and mapping process.22 6.1 Clearly declared purpose 22 6.2 Use scenarios to define purpose and use

7、r requirements 23 6.3 Machine processable format 24 6.4 Identify the versions .24 6.5 Development/maintenance team skills . .24 6.6 Conventions and rules followed 24 6.7 Involve custodians and users .25 6.8 Open and documented map production processes 25 6.9 Describe the direction of the map .26 6.1

8、0 Clearly specified cardinality .27 6.11 Explicit specification of loss or gain of meaning .28 6.12 Demonstrate the degree of equivalence of the map 29 6.13 Explicit guidelines and heuristics applied in development and for implementation .30 6.14 Documented map sets/data structures, distribution for

9、mat, and licensing 31 6.15 Quality assurance plan 31 6.16 Consensus management process .31 6.17 Validation 31 6.18 Maintenance and evaluation plan 32 6.19 Supporting documentation of mapping process 33 6.20 Build and manage through a mapping team 33 6.21 Other opportunities .33 7 Map development and

10、 maintenance team 33 7.1 Mapping project roles and responsibilities .33 7.2 Map sponsor .34 7.3 Mapping manager 34 7.4 Mapping specialist team leader .34 7.5 Mapping specialists 35 7.6 Clinical support .35 ISO/TR 12300:2014(E)iv ISO 2014 All rights reserved 7.7 Consensus management specialists 35 7.

11、8 Information technology support 35 7.9 Other members 36 Bibliography .37 ISO/TR 12300:2014(E) Foreword ISO (the International Organization for Standardization) is a worldwide federation of national standards bodies (ISO member bodies). The work of preparing International Standards is normally carri

12、ed out through ISO technical committees. Each member body interested in a subject for which a technical committee has been established has the right to be represented on that committee. International organizations, governmental and non-governmental, in liaison with ISO, also take part in the work. I

13、SO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of electrotechnical standardization. The procedures used to develop this document and those intended for its further maintenance are described in the ISO/IEC Directives, Part 1. In particular the differen

14、t approval criteria needed for the different types of ISO documents should be noted. This document was drafted in accordance with the editorial rules of the ISO/IEC Directives, Part 2 (see www.iso.org/directives). Attention is drawn to the possibility that some of the elements of this document may b

15、e the subject of patent rights. ISO shall not be held responsible for identifying any or all such patent rights. Details of any patent rights identified during the development of the document will be in the Introduction and/or on the ISO list of patent declarations received (see www.iso.org/patents)

16、. Any trade name used in this document is information given for the convenience of users and does not constitute an endorsement. For an explanation on the meaning of ISO specific terms and expressions related to conformity assessment, as well as information about ISOs adherence to the WTO principles

17、 in the Technical Barriers to Trade (TBT), see the following URL: Foreword Supplementary information. The committee responsible for this document is ISO/TC 215, Health informatics. ISO 2014 All rights reserved v ISO/TR 12300:2014(E) Introduction The benefits of data sharing and reuse are well known.

18、 One of the key principles underpinning health informatics is that data should be collected once and reused to the greatest extent possible. Mapping is the process of associating concepts from one terminological resource to concepts in another terminological resource and defining their equivalence i

19、n accordance with a documented rationale and a given purpose. The terminological resources can be related (different versions of the same resource) or completely different resources. The process of mapping identifies whether there is a relationship between the concepts and, if so, the level of meani

20、ng expressed by that relationship. It is a way to integrate different terminological resources used for different purposes and where a bridge between them is required for interoperability and that bridge can be built through mapping. Thus, different data sources can be compared and linked to enable

21、the data to be exchanged between information systems, compared over time, or aggregated for different purposes. The end product (deliverable) of the process is a set of individual maps (relationships) between two terminological resources that defines the cardinality and degree of equivalence between

22、 concepts and rule set structures and enables the automated translation between the terminological resources. As an example in health care, data collected for communicating information about direct patient care (using clinical terminologies) can be reused for statistical and administrative reporting

23、 of morbidity data (using clinical classifications) by transforming the terminological representations into classification representations. Terminological resources include all mechanisms for representation of data including terminologies, classifications, and code systems. Quality maps are always b

24、uilt for a purpose. Skilled mapping personnel are required to ensure the quality and integrity of map development and mapping rules. The development of rules (either paper- based or computer algorithms) that support conversion of data are crucial to standardize the process and create logical maps th

25、at a computer can use repeatedly to consistently convert data from one form to another. This Technical Report provides guidance for organizations charged with creating or applying maps to meet their business needs. It identifies issues and discusses both the potential in and the limitations of apply

26、ing the map. This Technical Report also establishes and harmonizes the basic principles for developing, maintaining, and using maps and gives guidelines for good practice that underpin the mapping process. This Technical Report does not provide information or guidance on processes required to produc

27、e a map in any given situation nor the intellectual property rights of those who own the various terminologies or classifications. There is a lack of common understanding of the need for mapping between terminological resources, the process of mapping, and requirements for computational functionalit

28、y in the mapped relationships between the different terminological resources used in health care. Thus, documenting the general principles that underpin the mapping process are essential to good decision making and governance. These will provide guidance about good practice, will support convergence

29、 of international knowledge, standardize processes, structure, and approach to the development of infrastructure and tools supporting the mapping process. There are broadly three core reasons to map data from one code system to another through a map. These include the following: support interoperabi

30、lity (information sharing between systems and organizations); reuse of data collected for one purpose to meet another purpose (secondary use); convert from an older, no longer relevant to purpose terminological resource to a new alternative representation. Information sharing might require informati

31、on collected in the local system to be converted to a “common language” such as that represented by international standard terminological resources such vi ISO 2014 All rights reserved ISO/TR 12300:2014(E) as SNOMED CT or ICD. The common language should be agreed upon in order for computer systems t

32、o communicate effectively. Any information in local systems not in the common language should be translated (mapped) into the common language and when information is received from others, it should be converted from the common language into the language of the local system. The increasing use of ter

33、minologies to collect data supporting direct patient care has enabled the reuse of this data for other purposes. Data collected for secondary use are generally aggregated and collected through classifications. Secondary use includes, but is not limited to, reusing the information for the following p

34、urposes: a) funding; b) statistical aggregation and reporting (morbidity and mortality); c) providing a research basis for evidence-based medicine; d) measuring quality and safety of care; e) health planning or setting health policy; f) monitoring resource utilization; g) public health surveillance.

35、 Reusing the data through mapping reduces the need for recollection of data, thereby simplifying the administrative burden of data collection, although it should be understood that the administrative burden might increase overall due to the maintenance of mapping when continuing to use multiple code

36、 systems and maps. Facilitating the automation between various terminological systems used in health care reduces the costs of providing care and improves the quality of the data and the timeliness (availability). Decisions on whether or not to map or whether to move from, for example, a classificat

37、ion of clinical information to a more precise clinical terminology needs to be based upon a wide range of factors including the ability to accurately represent meaning, the need to represent information in a manner suited to purpose in each use environment, including the need to aggregate and compar

38、e data over time. There are also significant costs and skills associated with mapping. The difference between a “once off” map table to meet a singular, conversion process and the decision to use maps as a long- term mechanism to support reporting and analysis need to be understood by those making d

39、ecisions on these infrastructure approaches recognizing all of the benefits, requirements, and costs which might include the following: decision makers in government, healthcare authorities, and healthcare facilities; developers, implementers and managers of health information systems, clinical info

40、rmation systems and clinical decision support systems; classification and terminology communities of practice; all users of clinical data, such as health statisticians, researchers, public health agencies, health insurance providers, health risk organizations, data analysts, and data managers; In th

41、is Technical Report, mapping refers to the establishment of semantic comparability between terminological resources (these resources include terminologies, classifications and other code systems), the term “concept” is applied throughout this Technical Report to represent a “unit of thought” express

42、ed in a terminology (it should also be noted that some terminological systems do not explicitly represent concepts, but rather terms, i.e. meaning cannot be assumed explicitly by the code or terms used), and ISO 2014 All rights reserved vii ISO/TR 12300:2014(E) the term “terminological resource” is

43、applied throughout this Technical Report to collectively mean either a classification or a terminology used to classify or encode data in healthcare. Examples are drawn from the published literature on mapping to illustrate key concepts and enhance understanding. However, full and complete understan

44、ding of the principles and guidelines requires some background knowledge of the coding of healthcare data, the various terminological systems used, and the many uses of the coded data.viii ISO 2014 All rights reserved Health informatics Principles of mapping between terminological systems 1 Scope Th

45、is Technical Report provides guidance for organizations charged with creating or applying maps to meet their business needs. It explains the risks inherent in the mapping process and discusses the issues that need to be considered in the development, maintenance, and use of maps in health care. This

46、 Technical Report also identifies variations in process, precision, and administration when mapping for different purposes and in different environments. Importantly, this Technical Report establishes and harmonizes the basic principles for developing, maintaining, and using maps and gives guideline

47、s for good practice that underpin the mapping process. Terminological resources includes terminologies, classifications, and code systems used in the regulatory environment as it relates to healthcare and reporting requirements in healthcare. This Technical Report is general in nature and does not d

48、escribe the specific methods applied in the mapping process nor does it describe maps between databases and data sets, even though many of the principles stated here will apply to those types of maps. This Technical Report does not include consideration of the intellectual property rights and expect

49、ations of the owners of terminologies or classifications. It is the responsibility of the mapper and process to ensure that these legal rights are protected and acknowledged as part of the mapping processes. 2 T erms a nd definiti ons Where there are terms used in this document that are not defined in this clause, they are considered to be generic to the English language and not specific to this document. Additional definitions and terms can be found at the international health informatics Standards Knowledge Management Tool and Glo