ASTM E2473-2005(2011) 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: E2473 05 (Reapproved 2011)An American National StandardStandard 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

2、 adoption or, in the case of 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/environ

3、mental health view 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

4、 Concept Data Model 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 port

5、ions of occupational/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

6、 are dealt with in otherdomains.2. Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Health Record (EHR) SystemsE1340 Guide for Rapid Prototyping of Information SystemsE1384 Practice for Con

7、tent and Structure of the ElectronicHealth Record (EHR)E1578 Guide for Laboratory Information Management Sys-tems (LIMS)E1633 Specification for Coded Values Used in the Elec-tronic Health RecordE1714 Guide for Properties of a Universal HealthcareIdentifier (UHID)E1715 Practice for An Object-Oriented

8、 Model for Registra-tion, Admitting, Discharge, and Transfer (RADT) Func-tions in Computer-Based Patient Record SystemsE1744 Practice for View of Emergency Medical Care in theElectronic Health RecordE1762 Guide for Electronic Authentication of Health CareInformationE1869 Guide for Confidentiality, P

9、rivacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE1986 Guide for Information Access Privileges to HealthInformationE1987 Guide for Individual Rights Regarding Health Infor-mation3E1988 Guide for Training of Persons who have Access toHealth Inform

10、ation3E2017 Guide for Amendments to Health InformationE2066 Guide for Validation of Laboratory InformationManagement SystemsE2084 Specification for Authentication of Healthcare Infor-mation Using Digital Signatures3E2085 Guide on Security Framework for Healthcare Infor-mation3E2086 Guide for Interne

11、t and Intranet Healthcare Security3E2145 Practice for Information ModelingE2147 Specification for Audit and Disclosure Logs for Usein Health Information SystemsE2171 Practice for Rating-Scale Measures Relevant to theElectronic Health Record2.2 ANSI/IEEE Standards:4ANSI/IEEE 610.2 Standard Glossary o

12、f Computer 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-ing1This practice is under the jurisdiction of ASTM Committee E31 on

13、 HealthcareInformatics and is the direct 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/E2

14、473-05R11.2For 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. The last approved version of this histo

15、rical standard is referencedon www.astm.org.4Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.ANSI/IEEE 830

16、Software Requirements SpecificationANSI/IEEE 1058 Software Project Management PlansANSI/IEEE 1062 Recommended Practice for Software Re-quirementsANSI/IEEE 1063 Software User DocumentationANSI/IEEE 1073 Framework and OverviewANSI/IEEE 1073.2 Application Profile Framework andOverviewANSI/IEEE 1073.3.1

17、 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 Application and Manage-ment of the System Engineering ProcessANSI/IEEE 1233 Guide to P

18、reparing System RequirementsSpecificationsANSI/IEEE 1320.1 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF0ANSI/IEEE 1320.2 Standard for Conceptual ModelingLanguageSyntax and Semantics for IDEF1X97 (IDEFObject)ANSI/IEEE 1362 Guide for Information TechnologySystem DefinitionConc

19、ept of Operations DocumentANSI/IEEE 1490 Guide to Project Management Body ofKnowledgeANSI/IEEE 1498 Trial Use Standard for InformationTechnologySoftware LifeCycle ProcessesSoftwareDevelopment: AcquirerSupplier AgreementANSI/IEEE 12207.0 Standard for InformationTechnologySoftware Life Cycle Processes

20、ANSI/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 Trial Use Standard for Healthcare DataInterchangeInformation Model Methods2.3 ANSI/H

21、L7 Standards:4ANSI/HL7 Interface Standard v2.4HL7 Message Development Framework v 3.0 Jan 19972.4 ISO Standards:4ISO/IEC TR 9789 Information TechnologyGuidelines forthe Organization and Representation of Data Elements forData InterchangeCoding Methods and PrinciplesISO 12200 Computer Applications in

22、 TerminologyMachine-Readable Terminology Interchange Format(MARTIF)Negotiated InterchangeISO 12620 Computer Applications in TerminologyDataCategoriesISO IS 12207 Information Technology-Software Life CycleProcessesISO IS 15188 Project Management Guidelines for Termi-nology StandardizationISO WD 15288

23、 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 Introduction, Model Architecture, andSpecification FrameworkANSI/ADA 1000.1 Indivi

24、dual 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 CommunicationANSI/ADA 1000.8 Healthcare EventANSI/ADA 1000.9 Health MaterielANSI/ADA 1000.1

25、0 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/ADA 1000.16 Patient Health ServiceANSI/ADA 1000.17 Clinical InvestigationANSI/ADA

26、 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 theExchange of Laboratory InformationCEN ENV 1614 Healthcare InformaticsStructure for No-m

27、enclature, 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 Semantics(MOSE)Internet RFC 1521 N. Borenstein, N Freed MIME Multi-purpose Internet

28、 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-A Laboratory Automation: Bar codes forSpecimen Container IdentificationCLSI AUTO3

29、-A Laboratory Automation: Communicationswith Automated Clinical Laboratory Systems, Instru-ments, Devices and Information SystemsCLSI AUTO4-A Laboratory Automation: Systems Opera-tional Requirements, Characteristics and Information El-ementsCLSI AUTO5-A Laboratory Automation: Electromechani-cal Inte

30、rfacesANSI/ 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-nanceE2473 05 (2011)2CLSI LIS-3A(priorASTM E792) Guide for Procurement ofa Clini

31、cal Laboratory 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

32、and Computer 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 Functio

33、nalRequirements 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 Pr

34、operties 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 Properties and Units in Clinical Pharmacol-ogy and Toxicology3. Terminology3.1 D

35、efinition: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 states.3.2 Acronyms:3.2.1 CAPCollege of American Pathologists3.2.2 CDCCente

36、rs 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 Institute3.2.6 CPRComputer-based Patient Record3.2.7 DHHSDepartment of Health an

37、d 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 Systems3.2.14 ISAInformation Systems Architecture3.2.15 LASLaboratory Automation

38、 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 HealthStatistics3.2.21 NIOSHNational Institute for Occupational Safetyand Health

39、3.2.22 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 PPOPreferred Provider Organization3.2.29 SSANSocial Security Account Number (a

40、lso 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 application ofexisting conventions for the structure and content of EHRsystems us

41、ed 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 documentalso recognizes the interaction of care rendered over a lifetimeand whe

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

43、identiality 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 programs

44、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 incurred

45、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 occurring in

46、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

47、” 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 and the record will be interoper-able with other standards conformant syste

48、ms, regardless oftheir implementation techniques. Fig. 1 shows the inter-relationships of the basic information domains that supportE2473 05 (2011)3Occupational/Environmental Health programs within health-care. The Care Record subdomain embraces the conceptualcontent and structure that have been doc

49、umented in PracticeE1384 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 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