ANSI ASTM E2473-2005 Standard Practice for the Occupational Environmental Health View of the Electronic Health Record.pdf

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1、Designation: E2473 05 (Reapproved 2011)Standard Practice for theOccupational/Environmental Health View of the ElectronicHealth Record1This standard is issued under the fixed designation E2473; the number immediately following the designation indicates the year oforiginal adoption or, in the case of

2、revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This Practice is intended to assemble a logicaloccupational/environmental health view of the alr

3、eady definedgeneral structure and vocabulary for the Electronic HealthRecord (EHR) and to suggest the ways in which this view canbe used to support employee health assessments and otherhealthcare delivered at the work site. This view is consistentwith theANSI/ADAClinical Concept Data Model 2005, whi

4、chidentified the major data entities that will need to be involved.This view would complement other views addressed in othersettings of care for the employee and could logically eitherrequest other EHR data or deliver to other practitioner request-ers record systems portions of occupational/environm

5、entalhealth data that have been recorded at the work site. Thispractice does not deal with the specific implementation of thecontent and it also does not either suggest or recommendimplementation techniques. Likewise, it does not suggeststandards of care. These functions are dealt with in otherdomai

6、ns.1.2 This international standard was developed in accor-dance with internationally recognized principles on standard-ization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers

7、 to Trade (TBT) Committee.2. Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) Systems (Withdrawn2017)3E1340 Guide for Rapid Prototyping of Information Systems(Withdrawn

8、2017)3E1384 Practice for Content and Structure of the ElectronicHealth Record (Withdrawn 2017)3E1578 Guide for Laboratory InformaticsE1633 Specification for Coded Values Used in the ElectronicHealth Record (Withdrawn 2017)3E1714 Guide for Properties of a Universal Healthcare Iden-tifier (UHID)E1715

9、Practice for An Object-Oriented Model forRegistration, Admitting, Discharge, and Transfer (RADT)Functions in Computer-Based Patient Record Systems(Withdrawn 2017)3E1744 Practice for View of Emergency Medical Care in theElectronic Health Record (Withdrawn 2017)3E1762 Guide for Electronic Authenticati

10、on of Health CareInformation (Withdrawn 2017)3E1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health Records (Withdrawn 2017)3E1986 Guide for Information Access Privileges to HealthInformation (Withdrawn 2017)3E1987 Guide for

11、 Individual Rights Regarding Health Infor-mation (Withdrawn 2007)3E1988 Guide for Training of Persons who have Access toHealth Information (Withdrawn 2007)3E2017 Guide for Amendments to Health Information (With-drawn 2017)3E2066 Guide for Validation of Laboratory Information Man-agement Systems (Wit

12、hdrawn 2015)3E2084 Specification for Authentication of Healthcare Infor-mation Using Digital Signatures (Withdrawn 2009)3E2085 Guide on Security Framework for Healthcare Infor-mation (Withdrawn 2009)31This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the d

13、irect responsibility of Subcommittee E31.25 on HealthcareData Management, Security, Confidentiality, and Privacy.Current edition approved May 1, 2011. Published May 2011. Originallyapproved in 2005. Last previous edition approved in 2005 as E2473 05. DOI:10.1520/E2473-05R11.2For referenced ASTM stan

14、dards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.Co

15、pyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for theDevelopment of Interna

16、tional Standards, Guides and Recommendations issued by the World Trade Organization Technical Barriers to Trade (TBT) Committee.1E2086 Guide for Internet and Intranet Healthcare Security(Withdrawn 2009)3E2145 Practice for Information Modeling (Withdrawn2017)3E2147 Specification for Audit and Disclos

17、ure Logs for Usein Health Information Systems (Withdrawn 2017)3E2171 Practice for Rating-Scale Measures Relevant to theElectronic Health Record (Withdrawn 2017)32.2 ANSI/IEEE Standards:4ANSI/IEEE 610.2 Standard Glossary of Computer Applica-tions TerminologyANSI/IEEE 610.5 Standard Glossary of Inform

18、ation Man-agement TerminologyANSI/IEEE 610.12 Standard Glossary of Software Engi-neering TerminologyANSI/IEEE 729 Fundamental Terms in Software Engineer-ingANSI/IEEE 830 Software Requirements SpecificationANSI/IEEE 1058 Software Project Management PlansANSI/IEEE 1062 Recommended Practice for Softwar

19、e Re-quirementsANSI/IEEE 1063 Software User DocumentationANSI/IEEE 1073 Framework and OverviewANSI/IEEE 1073.2 Application Profile Framework andOverviewANSI/IEEE 1073.3.1 Transport ProfileANSI/IEEE 1073.4.1 Physical Layer-Cable ConnectedANSI/IEEE 1074 Standard for Developing Life Cycle Pro-cessesANS

20、I/IEEE 1074.1 Guide for Developing Life Cycle Pro-cessesANSI/IEEE 1220 Standard forApplication and Managementof the System Engineering ProcessANSI/IEEE 1233 Guide to Preparing System RequirementsSpecificationsANSI/IEEE 1320.1 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF0ANSI

21、/IEEE 1320.2 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF1X97 (IDEFObject)ANSI/IEEE 1362 Guide for Information TechnologySystem DefinitionConcept of Operations DocumentANSI/IEEE 1490 Guide to Project Management Body ofKnowledgeANSI/IEEE 1498 Trial Use Standard for Informatio

22、nTechnologySoftware LifeCycle ProcessesSoftwareDevelopment: AcquirerSupplier AgreementANSI/IEEE 12207.0 Standard for InformationTechnologySoftware Life Cycle ProcessesANSI/IEEE 12207.1 Guide for Information TechnologySoftware Life Cycle ProcessesLife Cycle DataANSI/IEEE 12207.2 Guide for Information

23、 TechnologySoftware Life Cycle ProcessesImplementation Consid-erationsIEEE P1157.1 Trial Use Standard for Healthcare DataInterchangeInformation Model Methods2.3 ANSI/HL7 Standards:4ANSI/HL7 Interface Standard v2.4HL7 Message Development Framework v 3.0 Jan 19972.4 ISO Standards:4ISO/IEC TR 9789 Info

24、rmation TechnologyGuidelines forthe Organization and Representation of Data Elements forData InterchangeCoding Methods and PrinciplesISO 12200 Computer Applications in TerminologyMachine-Readable Terminology Interchange Format(MARTIF)Negotiated InterchangeISO 12620 Computer Applications in Terminolo

25、gyDataCategoriesISO IS 12207 Information Technology-Software Life CycleProcessesISO IS 15188 Project Management Guidelines for Terminol-ogy StandardizationISO WD 15288 System Life Cycle ProcessesISO 15440 Guide for Life Cycle Processes2.5 Other Standards:ANSI X3.172 American National Dictionary for

26、Informa-tion SystemsANSI/ADA TR 1039 2005 Clinical Content Data ModelANSI/ADA 1000.0 Introduction, Model Architecture, andSpecification FrameworkANSI/ADA 1000.1 Individual IdentificationANSI/ADA 1000.2 Codes and NomenclatureANSI/ADA 1000.3 Individual CharacteristicsANSI/ADA 1000.4 Population Charact

27、eristicsANSI/ADA 1000.5 OrganizationANSI/ADA 1000.6 LocationANSI/ADA 1000.7 CommunicationANSI/ADA 1000.8 Healthcare EventANSI/ADA 1000.9 Health MaterielANSI/ADA 1000.10 Health ServicesANSI/ADA 1000.11 Health Service ResourcesANSI/ADA 1000.12 Population Health FactsANSI/ADA 1000.13 Patient Health Fac

28、tsANSI/ADA 1000.14 Health Condition DiagnosisANSI/ADA 1000.15 Health Service PlanANSI/ADA 1000.16 Patient Health ServiceANSI/ADA 1000.17 Clinical InvestigationANSI/ADA 1000.18 Comments Subject AreaDICOM Supplement 15 Visible Light Image, AnatomicFrame of Reference, Accession and Specimen forEndoscop

29、y, Microscopy, and PhotographyCEN ENV 1613 Medical InformaticsMessages for theExchange of Laboratory InformationCEN ENV 1614 Healthcare InformaticsStructure forNomenclature, Classification and Coding of Properties inClinical Laboratory SciencesCEN EN 12017 Medical Informatics Vocabulary (MIVoc)CEN E

30、N 12264 Categorical Structures of Systems ofConceptsModel for Representation of Semantics(MOSE)Internet RFC 1521 N. Borenstein, N Freed MIME Multi-purpose Internet Mail Extensions Purpose: Mechanismsfor Specifying and Designating the Format of Internet4Available from American National Standards Inst

31、itute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.E2473 05 (2011)2Message Bodies Bellcore Innosoft Sep 1993ANSI X12CLSI AUTO1-A Laboratory Automation: SpecimenContainer/Specimen CarrierCLSI AUTO2-A Laboratory Automation: Bar codes forSpecimen Container IdentificationCLSI

32、 AUTO3-A Laboratory Automation: Communicationswith Automated Clinical Laboratory Systems,Instruments, Devices and Information SystemsCLSI AUTO4-A Laboratory Automation: Systems Opera-tional Requirements, Characteristics and Information El-ementsCLSIAUTO5-A LaboratoryAutomation: ElectromechanicalInte

33、rfacesANSI/ CLSI ASTP2 Point of Care In-vitro Diagnostic Test-ingANSI/CLSI GP19 Laboratory Instruments and Data Man-agement Systems: Design of Software User Interfaces andSoftware Systems Validation, Operations and Mainte-nanceCLSI LIS-3A (prior ASTM E792) Guide for Procurement ofa Clinical Laborato

34、ry Information Management System(CLIMS)CLSI LIS-5A (prior ASTM E1238) Specification for Trans-ferring Clinical Observations Between Independent Com-puter SystemsCLSI LIS-1A (prior ASTM E1381) Specification for LowLevel Protocol to Transfer Messages Between ClinicalLaboratory Instruments and Computer

35、 SystemsCLSI LIS-2A (prior ASTM E1394) Specification for Trans-ferring Information Between Clinical Instruments andComputer SystemsCLSI LIS-7A (prior ASTM E1466) Specification for Use ofBar Codes on Specimen Tubes in the Clinical LaboratoryCLSI LIS-8A (prior ASTM E1639) Guide for FunctionalRequireme

36、nts of Clinical Laboratory Information Man-agement SystemsCLSI LIS-9A (prior ASTM E2118) Guide for Coordinationof Clinical Laboratory Services Within the ElectronicHealth record Environment and Networked ArchitecturesIUPAC/IFCC Silver Book: Compendium of Terminologyand Nomenclature of Properties in

37、Clinical LaboratorySciencesIUPAC/IFCC Properties and Units in Clinical LaboratorySciences X Properties and Units in General ClinicalChemistryIUPAC/IFCC Properties and Units in Clinical LaboratorySciences XII Properties and Units in Clinical Pharmacol-ogy and Toxicology3. Terminology3.1 Definitions:3

38、.1.1 casean Occupational/Environmental Health event inwhich one or more individuals and locations are found toexhibit measurements of environmental stressors that are atvariance with criteria that define normative states.3.2 Acronyms:3.2.1 CAPCollege of American Pathologists3.2.2 CDCCenters for Dise

39、ase Control and Prevention,Dept. of Health and Human Services3.2.3 CDSSClinical Decision Support Systems3.2.4 CLIMSClinical Laboratory Information Manage-ment System3.2.5 CLSIClinical and Laboratory Standards Institute3.2.6 CPRComputer-based Patient Record3.2.7 DHHSDepartment of Health and Human Ser

40、vices3.2.8 ECElectronic Commerce3.2.9 EDIElectronic Data Interchange3.2.10 EHRElectronic Health Record3.2.11 EPAEnvironmental Protection Agency3.2.12 HINHealth Information Network3.2.13 IDSIntegrated Delivery Systems3.2.14 ISAInformation Systems Architecture3.2.15 LASLaboratory Automation System3.2.

41、16 LIMSLaboratory Information Management System3.2.17 MDSSManagement Decision Support System3.2.18 MCOManaged Care Organization3.2.19 MPIMaster Person/Patient Index3.2.20 NCVHSNational Committee on Vital and HealthStatistics3.2.21 NIOSHNational Institute for Occupational Safetyand Health3.2.22 NPFNa

42、tional Provider File3.2.23 NPINational Provider Identifier3.2.24 NPSNational Provider System3.2.25 OSHAOccupational Safety and Health Administra-tion3.2.26 POCPoint-of-Care3.2.27 POCTPoint-of-Care Testing3.2.28 PPOPreferred Provider Organization3.2.29 SSANSocial Security Account Number (also SSN)3.2

43、.30 UMLSUnified Medical Language System3.2.31 VHAVeterans Health Administration3.2.32 VistAVHA Information Systems Technology Ar-chitecture4. Significance and Use4.1 This practice is directed at defining the application ofexisting conventions for the structure and content of EHRsystems used to suppo

44、rt healthcare practitioners in a workplacesetting. In addition to supporting the capture of data onencounters and of periodic patient health assessments con-ducted during the time the employee is at work, this documentalso recognizes the interaction of care rendered over a lifetimeand when not at wo

45、rk with that due to the work environmentthat is delivered on the work site, either for care events thathave occupational significance or for surveillance of potentialhealth conditions that may result from the work or livingenvironment. This document recognizes not only the privacyE2473 05 (2011)3and

46、 confidentiality of records that are kept in the work settingbut also the need to be able to interchange data from theworkplace record with health records in other settings in orderto fully support employee and environmental health.4.2 Occupational Health Programs:4.2.1 Most occupational health prog

47、rams are oriented, first,to any regular surveillance for observations associated withpotentially adverse health conditions known to attend environ-mental stressors that may be present in either the workplace orthe living environment and, second, to care and documentationof any illness or injury incu

48、rred during the workday at the worksite or in other living environments. Each of these activitiesrequires recording data for the care record that is a subset ofthat regularly required for care in other more extensiveambulatory and inpatient care settings. It also requires relatingthe events occurrin

49、g in either the work place or the livingenvironment to those observed healthcare data.4.2.2 This practice is intended to identify the most fre-quently used of the general data elements which are morecompletely documented in Practice E1384 and SpecificationE1633. Thus, this description constitutes a “view” of the morecomprehensive set of data that might be captured in a generalambulatory care encounter. If the conventions given in thisdocument are adhered to, the data will ensure a record that isportable to any other setting