ASTM E2457-2007 Standard Terminology for Healthcare Informatics《保健信息学标准术语》.pdf

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1、Designation: E 2457 07Standard Terminology forHealthcare Informatics1This standard is issued under the fixed designation E 2457; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revision, the year of last revision. A number in parentheses ind

2、icates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.1. Scope*1.1 This terminology is intended to name and document theprincipal concepts, and their associated terms, that are utilizedin the healthcare information domain and

3、 all of its specializedsubdomains. It is applicable to all areas of healthcare aboutwhich information is kept or utilized. It is intended to comple-ment and utilize those concepts already identified by othernational and international standards bodies. It will identifyalternate accepted terms for the

4、 same concept and its electedterm. Its terms are intended to clarify and simplify usage in thedialog and documentation about the concepts, processes anddata that are used to schedule, conduct and manage all phasesof healthcare. This common usage will improve the quality andmanagement of all facets o

5、f healthcare by means of explicitinformation used in referring to each of these facets. Thesehealth informatics terms have been collected here specificallyin order to facilitate the consistent use of common concepts ininformatics standards development and use throughout health-care. A separate proce

6、ss from this standard that is described inISO 15188 will manage the approval of biomedical and health-care terms.1.2 This standard does not purport to address all of thesafety concerns, if any, associated with its use. It is theresponsibility of the user of this standard to establish appro-priate sa

7、fety and health practices and determine the applica-bility of regulatory limitations prior to use.2. Referenced Documents2.1 ASTM Standards:2E 1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT)Systems for Electronic Health Record (EHR) SystemsE 1284 Guid

8、e for Construction of a Clinical Nomenclaturefor Support of Electronic Health Records3E 1384 Practice for Content and Structure of the ElectronicHealth Record (EHR)E 1633 Specification for Coded Values Used in the Elec-tronic Health RecordE 1762 Guide for Electronic Authentication of Health CareInfo

9、rmationE 1869 Guide for Confidentiality, Privacy,Access, and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE 1985 Guide for User Authentication and AuthorizationE 1986 Guide for Information Access Privileges to HealthInformationE 1987 Guide for Individual Rights

10、Regarding Health In-formationE 2087 Specification for Quality Indicators for ControlledHealth VocabulariesE 2147 Specification for Audit and Disclosure Logs for Usein Health Information Systems2.2 CEN Standards:4EN-12017 Medical Informatics Vocabulary (MIVoc)EN-12264 Categorical Structure of Syntax

11、of ConceptsModel for Representation of Semantics (MOSE)2.3 ISO Standards:5ISO 704 Principles and Methods of TerminologyISO/DIS 860 International Harmonization of Concepts andTermsISO/DIS 1087-1 TerminologyVocabularyPart 1 Theoryand ApplicationISO/DIS 1087-2 TerminologyVocabularyPart 2 Com-puter Appl

12、icationsISO 2382/4 Information TechnologyVocabularyOrganization of DataISO 10241 TerminologyStandards Representation andLayoutISO 12200 TerminologyComputer ApplicationsMachine Readable Terminology Interchange FormatISO/IEC 12207 Life Cycle ProcessesISO 12620 TerminologyComputer ApplicationsDataCateg

13、ories1This terminology is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.35 onHealthcare Data Analysis.Current edition approved July 15, 2007. Published August 2007. Originallyapproved in 2006. Last previous edition approved

14、 in 2006 as E 2457 06.2For referenced ASTM standards, 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.3Withdrawn.4Available from European Com

15、mittee for Standardization (CEN), 36 rue deStassart, B-1050, Brussels, Belgium, http:/www.cenorm.be.5Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.1*A Summary of Changes section appears at the end of this standard.Copyri

16、ght ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.ISO 15188 Project Management Guidelines for Terminol-ogy Interchange Format2.4 Other Documents:American National Standard Dictionary of InformationTechnology (ANSDIT) http:/www.incits.orgCEN P

17、rENV 11994 Medical Informatics VocabularyGALEN Generalized Architecture for Language, Encyclo-pedias and Nomenclatures in Medicine: Univ. ofManchesterIEEE 610.5 Glossary of Data ManagementUnified Medical Language System (UMLS) KnowledgeSources National Library of Medicine 7th ExperimentalEdition Jan

18、uary 19963. Significance and Use3.1 This standard vocabulary is intended to be used as areference about terms used in standards for healthcare infor-matics and in general discussions about informatics issuesrelating to the healthcare sector, including: clinical care,resource management, policy, clin

19、ical or health services re-search or biomedical research in basic or applied areas ofscience that refer to the healthcare sector. It contains “ElectedTerms” rather than the “Preferred” terms used in the termino-logic literature. This is a usage coined within the CEN TC-251community to reflect the fa

20、ct that there is consensus agreementon the usage of a particular form rather than an imposition.This consensual agreement to usage better reflects the incen-tives for common usage rather than mandates. Alternate forms(Synonymy) of an elected term exist and are cataloged for thesame concept, in accor

21、dance with ISO/DIS 1087-1, ISO 704,ISO 12620, and EN-12017, ISO/DIS 860, EN-12264, andANSDIT.3.2 The system used to classify these terms is in the fullcontext of all of the terminology of biomedicine, as well asabout the healthcare system itself as it is used throughout thehealth domain. It has draw

22、n on the terms used in bothEN-12017 and in UMLS for biomedicine (Guide E 1284,Specification E 1633, ISO 12200, GALEN). The codingscheme described in Section 5 used to represent this classifi-cation was developed for this terminology from the UnifiedMedical Language System documentation produced by t

23、heNational Library of Medicine.4. Terminology4.1 Vocabulary about VocabularyThis section lists thoseterms used for vocabulary in this document which do notappear in the above referenced standards; however, the follow-ing general terms in ISO/DIS 1087-1 are included for under-standing:4.2 ISO/DIS 108

24、7-1 Terms:admitted termterm accepted as a synonym for a preferredterm by an authoritative body.designationrepresentation of a concept by linguistic ornon-linguistic means.DISCUSSIONIn terminologic work, Symbols and Terms are the twodesignations.glossarydocument that contains a list of terms from a s

25、ubjectfield and their designations.preferred termterm recommended by an authoritative body.special languagelanguage for special purposes.technical dictionarydictionary of terminologic entries ordesignation-related information, from one or more specificsubject fields.termdesignation consisting of one

26、 or more words whichdenote a given concept in a special language (language forspecial purposes).terminologyset of terms belonging to one special language.vocabularytechnical dictionary that contains designationsand definitions from one or more special subject fields.4.3 Definitions of Terms Specific

27、 to This Standard:candidate termthat form which has been submitted to thereference body for election as that to be used in datainterchange and in situations requiring wide understandingbut which has not yet achieved that election.data element(1) named unit of data that, in some contexts,is considere

28、d indivisible and in other contexts may consist ofdata items; and (2) a named identifier of each of the entitiesand their attributes that are represented in a database.ANSI X3.172-1990data itemnamed component of a data element; usually thesmallest component. ANSI X3.172-1990data valueinstance of a d

29、ata item. ANSI X3.172-1990elected termthat form which is rapidly and fully understoodas representing the defined concept and which has beenagreed by consensus that it will stand for that concept in thewide majority of situations where that concept is noted.lexiconcollection of terms used in a partic

30、ular profession orsubject area.4.4 Acronyms:ANSI HITSPAmerican National Standards Institute HealthInformation Technology Standards PanelCENCommittee European NormalizationHL7Health Level SevenISOInternational Standards OrganizationSDOStandards Developer Organization5. Classification Schema5.1 The ra

31、tionale for placement of healthcare informaticsterms within an existing schema involves combination ofconcepts given in EN-12017 with that of the Semantic Typesused in UMLS (v-7, p. 30) by adding groups and subgroupsfrom EN-12017 to new sub categories in UMLS. The locationsof these insertions are sh

32、own as follows:EN 12017 classification shown in ( )Extensions to UMLS Semantic Type in BoldA. Entity2. Conceptual entity1. Idea or Concept2. Finding3. Organism Attribute4. Intellectual Product5. Language6. Occupation or Discipline1. Biomedicine Occupation or Discipline2. Professional, Service, Admin

33、istrative, Agricultural or ManufacturingOccupation7. Organization (1.2.3)1. Healthcare related organizationE24570721. Healthcare-delivery organization (1.2.3.1)2. Issuing organization (1.2.3.2)3. Registration authority (1.2.3.3)4. Sponsoring authority (1.2.3.4)5. Healthcare Facility2. Professional S

34、ociety3. Self-help or relief organization4. Healthcare party (1.2.4)1. Laboratory service provider (1.2.4.1)2. Laboratory service requester (1.2.4.2)3. Subject of Investigation (1.2.4.3)4. Consent (1.2.4.4)5. Healthcare accountability (1.2.5)1. Contract2. Management3. Professional License6. Healthca

35、re Enterprise (1.2.7.1)1. Healthcare enterprise constituencies (1.2.7.1.1)2. Healthcare enterprise dimensions (1.2.7.1.2)3. Healthcare enterprise view (1.2.7.1.3)7. Organizational policies (1.2.7.2)8. Organizational strategies (1.2.7.3)8. Group attribute9. Group1. Professional or Occupational Group1

36、. Healthcare Players (1.2)1. Healthcare professionals (1.2.2)1. Healthcare practitioner (1.2.2.1)2. Healthcare workers2. Population3. Family4. Age5. Patient or Disabled Group1. Individual Patient10. Resources (1.3)1. Healthcare Informatics (1.3.1)1. Health Information Technology (1.3.1.1)1. Health I

37、nformation Technology Components (1.3.1.1.1)2. Healthcare Technology (1.3.2)1. Health technology components (1.3.2.1)2. Interventional equipment (1.3.2.2)3. ECG Devices (1.3.2.3)4. Safety (1.3.2.4)3. Healthcare System/Setting11. Informatics (2.)1. Informatics Basics (2.1)1. Terminology (2.1.1)1. Con

38、cept (2.1.1.1)1. Concept Type (2.1.1.1.1)2. Concept System (2.1.1.1.2)3. Composite Concept (2.1.1.1.3)4. Type of Modifier (2.1.1.1.4)2. Characteristic (2.1.1.2)3. Term (2.1.1.3)4. Object (2.1.1.4)2. Modelling (2.1.2)1. Information Domain (2.1.2.1)2. Functional Domain (2.1.2.2)3. View (2.1.2.3)4. Mod

39、eling Technique (2.1.2.4)2. Information Systems (2.2)1. Information System (2.2.1)2. Information (2.2.2)3. Data Security (2.2.3)1. Confidentiality (2.2.3.1)2. Privacy (2.2.3.2)3. Cryptography (2.2.3.3)4. Access Control (2.2.3.4)5. Data Availability (2.2.3.5)6. Data Integrity (2.2.3.6)7. Security Aud

40、it (2.2.3.7)8. Security Policy (2.2.3.8)9. Threat (2.2.3.9)10. Physical Security (2.2.3.10)3. Processes (2.3)1. Data access (2.3.1)2. Imaging (2.3.2)3. Communication (2.3.3)4. Measurement (2.3.4)4. Devices (2.4)1. Intermittently Connected Device (2.4.1)2. Healthcare Person Device (2.4.2)3. Electroni

41、c Healthcare Cards (2.4.3)5. Data (2.5)1. Data types (2.5.1)2. Data structures (2.5.2)3. Codes (2.5.3)4. Record (2.5.4)1. Healthcare record (2.5.4.1)5. Register (2.5.5)6. Healthcare statistics (2.5.6)7. ECG Data (2.5.7)B. Event1. Activity3. Occupational Activity1. Healthcare Activity (1.1)1. Healthc

42、are Service (1.1.1)1. Diagnostic Procedure (1.1.1.1)1. Investigation (1.1.1.1.1)1. Laboratory Examination (1.1.1.1.1.1)2. Therapeutic/Preventive Procedure1. Surgical Deed (1.1.1.2)2. Nursing Procedure (1.1.1.3)3. Administrative service4. Clinical Service2. Ancillary Service (1.1.1.2)3. Telemedicine

43、(1.1.1.3)4. Healthcare Scheduling/appointing (1.1.2)5. Clinical Orders (1.1.3)1. Laboratory service order (1.1.3.1)6. Quality assurance (1.1.4)2. Research Activity3. Governmental or Regulatory Activity4. Educational Activity2. Phenomenon or Process1. Anthropogenic phenomenon2. Natural phenomenon1. B

44、iologic Function1. Physiologic Function2. Pathologic Function6. Terms and Definitions: Current Elected Terms6.1 Annex A1 contains the entries currently elected by thesubcommittees of ASTM Technical Committee E31 and sub-mitted to other SDOs of the ANSI HITSP. Terms not fullyagreed upon by these bodi

45、es are also listed in the next sectionon candidate terms. This Elected term list is prepared accord-ing to ISO 10241. A number of terms come from the CENStandard EN-12017 MIVOC.7. Terms and Definitions: Candidate Terms7.1 Annex A2 includes that list of candidate terms (withoutdefinitions) for which

46、full consensus has not yet been reachedbut which are widely used either in the elected or alternateforms. Continuing work is underway to elect the form which isintended to be that widely recognized for the defined concept.Upon election, the term entry (with elected definition) will betransferred to

47、Annex A1. Terms are further classified inAppendix X1 by the taxonomy given in 4.1.8. Keywords8.1 healthcare information domain; health informatics; ter-minology; vocabularyE2457073ANNEXES(Mandatory Information)A1. ELECTED TERMSACCESS(1) Possibility to retrieve medical information stored in a databas

48、e or remote application. Access should be limited by security authentication mechanisms.(2) The provision of an opportunity to approach, inspect, review, retrieve, store, communicate with or make use of health information system resources (for ex-ample, hardware, software, systems or structure) or p

49、atient identifiable data and information, or both. E 1869Source 3ACCESS CONTROLPrevention of use of a resource by unidentified or unauthorized entities or both. adapted from CEN/TC-251 directorySource 2ACCESS CONTROL LISTPiece of access control information, associated with a target, which specifies the initiators who may access some target.Source 16ACCOUNTABILITYProperty that ensures that actions of an entity may be traced uniquely to the entity. ISO 7498-2 Authority under which an action (a function, an activity, a task)is to be performed. I