ASTM E2473-2005 Standard Practice for the Occupational Environmental Health View of the Electronic Health Record《通过电子健康记录观察职业 环境健康情况的标准实施规程》.pdf

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1、Designation: E 2473 05An American National StandardStandard Practice for theOccupational/Environmental Health View of the ElectronicHealth Record1This standard is issued under the fixed designation E 2473; the number immediately following the designation indicates the year oforiginal adoption or, in

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

3、iew of the already 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 M

4、odel 2005, whichidentified 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 occupat

5、ional/environmentalhealth 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

6、 in otherdomains.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 1340 Guide for Rapid Prototyping of Information Sys-temsE 1384 Practice for Content and St

7、ructure of the ElectronicHealth Record (EHR)E 1578 Guide for Laboratory Information ManagementSystems (LIMS)E 1633 Specification for Coded Values Used in the Elec-tronic Health RecordE 1714 Guide for Properties of a Universal HealthcareIdentifier (UHID)E 1715 Practice for An Object-Oriented Model fo

8、r Regis-tration, Admitting, Discharge and Transfer (RADT) Func-tions in Computer-Based Patient Record SystemsE 1744 Practice for View of Emergency Medical Care in theElectronic Health RecordE 1762 Guide for Authentication of Healthcare InformationE 1869 Guide for Confidentiality, Privacy, Access and

9、 DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE 1986 Guide for Information Access Privileges to HealthInformationE 1987 Guide for Individual Rights Regarding Health In-formationE 1988 Guide for Training Persons Who Have Access toHealth InformationE 2017 Guide fo

10、r Amendments to Health InformationE 2066 Guide for Validation of Laboratory InformationManagement SystemsE 2084 Specification for Authentication of Healthcare In-formation Using Digital SignaturesE 2085 Guide on Security Framework for Healthcare Infor-mationE 2086 Guide for Internet and Intranet Hea

11、lthcare SecurityE 2145 Practice for Modeling in Health InformaticsE 2147 Specification for Audit and Disclosure Logs for Usein Health Information SystemsE 2171 Practice for Rating Scale Measures Relevant to theElectronic Health Record2.2 ANSI/IEEE Standards:3ANSI/IEEE 610.2 Standard Glossary of Comp

12、uter Applica-tions TerminologyANSI/IEEE 610.5 Standard Glossary of Information 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 Softwar

13、e Project Management Plans1This practice is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.25 on HealthcareData Management, Security, Confidentiality, and Privacy.Current edition approved July 17, 2006. Published December 20

14、05.2For 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.3Available from American National Standards Institute (ANS

15、I), 25 W. 43rd St.,4th Floor, New York, NY 10036.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.ANSI/IEEE 1062 Recommended Practice for Software Re-quirementsANSI/IEEE 1063 Software User DocumentationANSI/IEEE 1073 Framework and Ove

16、rviewANSI/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-cessesANSI/IEEE 1074.1 Guide for Developing Life Cycle Pro-cessesANSI/IEEE 1220 Standard for Appli

17、cation and Manage-ment of the System Engineering ProcessANSI/IEEE 1233 Guide to Preparing System RequirementsSpecificationsANSI/IEEE 1320.1 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF0ANSI/IEEE 1320.2 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF1X97

18、 (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 InformationTechnologySoftware LifeCycle ProcessesSoftwareDevelopment: AcquirerSupplier Agreement

19、ANSI/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 TechnologySoftware Life Cycle ProcessesImplementation Consid-erationsIEEE P1157.1 Tri

20、al Use Standard for Healthcare DataInterchangeInformation Model Methods2.3 ANSI/HL7 Standards:3ANSI/HL7 Interface Standard v2.4HL7 Message Development Framework v 3.0 Jan 19972.4 ISO Standards:3ISO/IEC TR 9789 Information TechnologyGuidelines forthe Organization and Representation of Data Elements f

21、orData InterchangeCoding Methods and PrinciplesISO 12200 Computer Applications in TerminologyMachine-Readable Terminology Interchange Format(MARTIF)Negotiated InterchangeISO 12620 Computer Applications in TerminologyDataCategoriesISO IS 12207 Information Technology-Software Life CycleProcessesISO IS

22、 15188 Project Management Guidelines for Termi-nology StandardizationISO WD 15288 System Life Cycle ProcessesISO 15440 Guide for Life Cycle Processes2.5 Other Standards:ANSI X3.172 American National Dictionary for Informa-tion SystemsANSI/ADA TR 1039 2005 Clinical Content Data ModelANSI/ADA 1000.0 I

23、ntroduction, Model Architecture, andSpecification FrameworkANSI/ADA 1000.1 Individual IdentificationANSI/ADA 1000.2 Codes and NomenclatureANSI/ADA 1000.3 Individual CharacteristicsANSI/ADA 1000.4 Population CharacteristicsANSI/ADA 1000.5 OrganizationANSI/ADA 1000.6 LocationANSI/ADA 1000.7 Communicat

24、ionANSI/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 FactsANSI/ADA 1000.14 Health Condition DiagnosisANSI/ADA 1000.15 Health Service PlanANSI/

25、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 for Endos-copy, Microscopy, and PhotographyCEN ENV 1613 Medical InformaticsMessages for theExchan

26、ge of Laboratory InformationCEN ENV 1614 Healthcare InformaticsStructure for No-menclature, Classification and Coding of Properties inClinical Laboratory SciencesCEN EN 12017 Medical Informatics Vocabulary (MIVoc)CEN EN 12264 Categorical Structures of Systems ofConceptsModel for Representation of Se

27、mantics(MOSE)Internet RFC 1521 N. Borenstein, N Freed MIME Multi-purpose Internet Mail Extensions Purpose: Mechanismsfor Specifying and Designating the Format of InternetMessage Bodies Bellcore Innosoft Sep 1993ANSI X12CLSI AUTO1-A Laboratory Automation: SpecimenContainer/Specimen CarrierCLSI AUTO2-

28、A Laboratory Automation: Bar codes forSpecimen Container IdentificationCLSI AUTO3-A Laboratory Automation: Communicationswith Automated Clinical Laboratory Systems, Instru-ments, Devices and Information SystemsCLSI AUTO4-A Laboratory Automation: Systems Opera-tional Requirements, Characteristics and

29、 Information El-ementsCLSI AUTO5-A Laboratory Automation: Electromechani-cal InterfacesANSI/ CLSI ASTP2 Point of Care In-vitro DiagnosticTestingANSI/CLSI GP19 Laboratory Instruments and Data Man-agement Systems: Design of Software User Interfaces andSoftware Systems Validation, Operations and Mainte

30、-nanceE2473052CLSI LIS-3A (prior ASTM E 792) Guide for Procurementof a Clinical Laboratory Information Management System(CLIMS)CLSI LIS-5A(priorASTM E 1238) Specification for Trans-ferring Clinical Observations Between Independent Com-puter SystemsCLSI LIS-1A (prior ASTM E 1381) Specification for Lo

31、wLevel Protocol to Transfer Messages Between ClinicalLaboratory Instruments and Computer SystemsCLSI LIS-2A(priorASTM E 1394) Specification for Trans-ferring Information Between Clinical Instruments andComputer SystemsCLSI LIS-7A(priorASTM E 1466) Specification for Use ofBar Codes on Specimen Tubes

32、in the Clinical LaboratoryCLSI LIS-8A (prior ASTM E 1639) Guide for FunctionalRequirements of Clinical Laboratory Information Man-agement SystemsCLSI LIS-9A (prior ASTM E 2118) Guide for Coordinationof Clinical Laboratory Services Within the ElectronicHealth record Environment and Networked Architec

33、turesIUPAC/IFCC Silver Book: Compendium of Terminologyand Nomenclature of Properties in Clinical LaboratorySciencesIUPAC/IFCC Properties and Units in Clinical LaboratorySciences X Properties and Units in General ClinicalChemistryIUPAC/IFCC Properties and Units in Clinical LaboratorySciences XII Prop

34、erties and Units in Clinical Pharmacol-ogy and Toxicology3. Terminology3.1 Definition:3.1.1 casean Occupational/Environmental Health eventin which one or more individuals and locations are found toexhibit measurements of environmental stressors that are atvariance with criteria that define normative

35、 states.3.2 Acronyms:3.2.1 CAPCollege of American Pathologists3.2.2 CDCCenters for Disease 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 Inst

36、itute3.2.6 CPRComputer-based Patient Record3.2.7 DHHSDepartment of Health and Human Services3.2.8 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 Syst

37、ems3.2.14 ISAInformation Systems Architecture3.2.15 LASLaboratory Automation System3.2.16 LIMSLaboratory Information Management Sys-tem3.2.17 MDSSManagement Decision Support System3.2.18 MCOManaged Care Organization3.2.19 MPIMaster Person/Patient Index3.2.20 NCVHSNational Committee on Vital and Heal

38、thStatistics3.2.21 NIOSHNational Institute for Occupational Safetyand Health3.2.22 NPFNational Provider File3.2.23 NPINational Provider Identifier3.2.24 NPSNational Provider System3.2.25 OSHAOccupational Safety and HealthAdministra-tion3.2.26 POCPoint-of-Care3.2.27 POCTPoint-of-Care Testing3.2.28 PP

39、OPreferred Provider Organization3.2.29 SSANSocial Security Account Number (also SSN)3.2.30 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 appli

40、cation ofexisting conventions for the structure and content of EHRsystems used to support 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 doc

41、umentalso recognizes the interaction of care rendered over a lifetimeand when not at work 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

42、 or livingenvironment. This document recognizes not only the privacyand 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 heal

43、th.4.2 Occupational Health Programs:4.2.1 Most occupational health programs 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 environm

44、ent and, second, to care and documentationof any illness or injury incurred 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 an

45、d inpatient care settings. It also requires relatingthe events occurring 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 Pract

46、ice E 1384 and SpecificationE 1633. 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 setti

47、ng and the record will be interoper-able with other standards conformant systems, regardless oftheir implementation techniques. Fig. 1 shows the inter-relationships of the basic information domains that supportE2473053Occupational/Environmental Health programs within health-care. The Care Record sub

48、domain embraces the conceptualcontent and structure that have been documented in PracticeE 1384 and associated standards. Resource Management andEpidemiology data analytic functions and subdomains aredocumented elsewhere in descriptions of the requirements ofthe HIPAA legislation and the CDC Public

49、Health InformationNetworkPHIN(X). The Occupational Health Programs aregenerally organized in employing organizations, but healthcareenterprises need to also recognize that they too are “employ-ers” in the same sense as any other societal business organi-zation and that their employees, including all healthcarepractitioners, as well as their associate professional disciplinecolleagues, are entitled to management of their occupationalhealth information by the same principles. Thus, occupationalhealth information management is int