BS DD ENV 12538-1998 Medical informatics - Messages for patient referral and discharge《医疗信息学 患者诊疗安排和出院的信息》.pdf

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1、DRAFT FOR DEVELOPMENT DD ENV 12538:1998 Medical informatics Messages for patient referral and discharge ICS 11.020; 35.240.70DDENV12538:1998 This Draft for Development, having been prepared under the direction of the DISC Board, was published under the authority of the Standards Committee and comes

2、into effect on 15 November 1998 BSI 06-1999 ISBN 0 580 30525 2 National foreword This Draft for Development is the English language version of ENV12538:1997. This publication is not to be regarded as a British Standard. It is being issued in the Draft for Development series of publications and is of

3、 a provisional nature due to the limited duration of the European prestandard. It should be applied on this provisional basis, so that information and experience of its practical application may be obtained. Comments arising from the use of this Draft for Development are requested so that UK experie

4、nce can be reported to the European organization responsible for its conversion into a European Standard. A review of this publication will be initiated 2 years after its publication by the European organization so that a decision can be taken on its status at the end of its three-year life. The com

5、mencement of the review period will be notified by an announcement in Update Standards. According to the replies received by the end of the review period, the responsible BSI Committee will decide whether to support the conversion into a European Standard, to extend the life of the prestandard or to

6、 withdraw it. Comments should be sent in writing to the Secretary of BSI Technical Committee IST/35, Medical informatics, at 389 Chiswick High Road, London W4 4AL, giving the document reference and clause number and proposing, where possible, an appropriate revision of the text. A list of organizati

7、ons represented on this committee can be obtained on request to its secretary. Cross-references The British Standards which implement international or European publications referred to in this document may be found in the BSI Standards Catalogue under the section entitled “International Standards Co

8、rrespondence Index”, or by using the “Find” facility of the BSI Standards Electronic Catalogue. Summary of pages This document comprises a front cover, an inside front cover, pages i and ii, theENV title page, pages 2 to 125 and a back cover. This standard has been updated (see copyright date) and m

9、ay have had amendments incorporated. This will be indicated in the amendment table on the inside front cover. Amendments issued since publication Amd. No. Date CommentsDDENV12538:1998 BSI 06-1999 i Contents Page National foreword Inside front cover Foreword 2 Text of ENV 12538 5ii blankEUROPEAN PRES

10、TANDARD PRNORME EUROPENNE EUROPISCHE VORNORM ENV 12538 March 1997 ICS 35.240.70 Descriptors: Data processing, information interchange, data transmission, medicine, messages English version Medical informatics Messages for patient referral and discharge Informatique de sant Messages pour ladresse dun

11、 patient un professionnel de sant et pour la sortie du patient Medizinische Informatik Nachrichten fr Zuweisung und Entlassung von Patienten This European Prestandard (ENV) was approved by CEN on 1997-02-09 as a prospective standard for provisional application. The period of validity of this ENV is

12、limited initially to three years. After two years the members of CEN will be requested to submit their comments, particularly, on the question whether the ENV can be converted into an European Standard (EN). CEN members are required to announce the existance of this ENV in the same way as for an EN

13、and to make the ENV available promptly at national level in an appropriate form. It is permissible to keep conflicting national standards in force (in parallel to the ENV) until the final decision about the possible conversion of the ENV into an EN is reached. CEN members are the national standards

14、bodies of Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and UnitedKingdom. CEN European Committee for Standardization Comit Europen de Normalisation Europisches Komitee fr Normung Central Se

15、cretariat: rue de Stassart 36, B-1050 Brussels 1997 Copyright reserved to CEN members Ref. No. ENV 12538:1997 EENV12538:1997 BSI 06-1999 2 Foreword This European Prestandard has been prepared by Technical Committee CEN/TC 251 “Medical informatics”, the secretariat of which is held by IBN. According

16、to the CEN/CENELEC Internal Regulations, the national standards organisations of the following countries are bound to announce this European Prestandard: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Sw

17、itzerland and the UnitedKingdom. Contents Page Foreword 2 Introduction 5 1 Scope 6 2 Normative references 7 3 Definitions and abbreviations 7 4 Requirements 10 5 Communication roles and supported services 10 5.1 General 10 5.2 Message groups 10 5.3 Communication roles 11 5.4 Communication roles and

18、General Message Descriptions 11 5.5 Communication roles and supported services 12 5.6 Message origination rules 13 6 Domain Information Model 13 6.1 Introduction 13 6.2 Domain information Model diagrams 16 6.3 Textual description of objects, their relationships and attributes 19 6.4 Textual descript

19、ion of common attribute groups 44 7 General Message Descriptions 47 7.1 Introduction 47 7.2 New specialist service request GMD 47 7.3 Specialist service request modification GMD 57 7.4 Specialist service request cancellation GMD 65 7.5 New specialist service report GMD 68 7.6 Specialist service repo

20、rt modification GMD 78 7.7 Specialist service report cancellation GMD 87 7.8 Attribute Layer 89 Annex A (normative) How to read the models 110 Annex B (informative) Relating the models to actual requests and reports 114 B.1 Introduction 114 B.2 Requesting specialist services(referral) 115 B.3 Report

21、ing of the provision of specialist services 117 Annex C (informative) Example scenarios of message use 120 C.1 Specialist services requests 120ENV12538:1997 BSI 06-1999 3 Page C.2 Specialist service reports 121 Index 124 Figure 1 Relationship between communication roles and GMDs 12 Figure 2 State tr

22、ansition rules for messages 14 Figure 3 Specialist service request and report model 16 Figure 4 Subject model for healthcare party 17 Figure 5 Subject model for patient 18 Figure 6 Subject model for clinical information item 18 Figure 7 Subject model for payment guarantor 19 Figure 8 New Specialist

23、Service Request: Top level model 48 Figure 9 New Specialist Service Request: Subject model for healthcare party 49 Figure 10 New Specialist Service Request: Subject model for patient 50 Figure 11 New Specialist Service Request: Subject model for clinical information item 51 Figure 12 New Specialist

24、Service Request: Subject model for payment guarantor 52 Figure 13 New Specialist Service Request: Hierarchical GMD 57 Figure 14 Specialist Service Request Modification: Top level model 58 Figure 15 Specialist Service Request Modification: Hierarchical GMD 64 Figure 16 Specialist Service Request Canc

25、ellation: Top level model 65 Figure 17 Specialist Service Request Cancellation: Subject model for healthcare party 66 Figure 18 Specialist Service Request Cancellation: Hierarchical GMD 68 Figure 19 New Specialist Service Report: Top level model 69 Figure 20 New Specialist Service Report: Subject mo

26、del for healthcare party 70 Figure 21 New Specialist Service Report: Hierarchical GMD 77 Figure 22 Specialist Service Report Modification: Top level model 79 Figure 23 Specialist Service Report Modification: Hierarchical GMD 86 Figure 24 Specialist Service Report Cancellation: Top level model 87 Fig

27、ure 25 Specialist Service Report Cancellation: Hierarchical GMD 89 Page Figure A-1 Legend 111 Figure A-2 Examples of model components 112 Figure A-3 Representation of cardinalities in the DIM compared with SSADM 113 Figure A-4 The notation used in hierarchical GMDs healthcare parties example 114 Tab

28、le 1 Message groups 11 Table 2 Description of data-types 20 Table 3 Attribute Layer 91 Table 4 Common Attribute Groups 108 Table B-1 115 Table B-2 1184 blankENV12538:1997 BSI 06-1999 5 Introduction The increased use of data processing and telecommunications capabilities has made possible the interch

29、ange of information in machine readable and machine processable formats. As automated interchange of information in healthcare increases, it is essential to provide appropriate information interchange standards. Computer systems are now used by many healthcare professionals for the storage and proce

30、ssing of information. Healthcare professionals request specialist services from one another by a process commonly called “referral”. The request for a service is usually accompanied by a relevant subset of the information held by the requesting healthcare professional about the referred patient. The

31、 recipient of a referral request usually reports on the progress and outcome of the requested service to the requester and to other healthcare professionals involved in the care of the patient. These reports may be made when the requested service is complete (commonly referred to as “discharge”) or

32、at other significant points in the delivery of the requested service. The information that is transferred in the requests and reports passing between healthcare professionals typically forms part of the administrative and clinical record of the patient held by each of the communicating parties. Elec

33、tronic transfer of these requests and reports reduces the need for manual data entry and the risk of transcription errors. It also results in greater efficiency leading to better healthcare provision. Standards are required to facilitate electronic transfer of requests for and results of the deliver

34、y of healthcare services between the many systems currently used. Implementation of this European Prestandard will therefore: a) facilitate the electronic transfer of requests for specialist services from requesting healthcare parties, to healthcare parties providing specialist services; b) facilita

35、te the electronic transfer of reports of specialist services from healthcare parties providing specialist services to requesting healthcare parties and to other healthcare parties involved in the care of a patient; c) reduce the need for human intervention in information interchange between applicat

36、ions used by specialist service providers and those used by other healthcare parties; d) minimise the time and effort required for the introduction of information interchange agreements; e) reduce the development effort required by suppliers to allow communication between a wide range of application

37、s in this field; f) reduce (in consequence of the foregoing) the cost of information interchange between specialist service providers and parties requesting specialist services. When implementing information exchange based upon this European Prestandard data protection and secrecy principles must be

38、 guaranteed according to the laws actually in force in the different CEN member countries. The method by which this European Prestandard has been developed is based on the recommendations of the CEN Technical Report “Investigation of Syntaxes for Existing Interchange Formats to be used in Healthcare

39、” (CR 1350:1993), and as extended in the First Working Document produced by PT3-025. This standard is intended for use by message developers. Its provisions are directly relevant to suppliers of computer systems for use in diagnostic service departments, hospitals, general practices, clinical depart

40、ments and specialist clinics. Its provisions are also relevant to those planning, specifying, procuring or implementing information systems for use in hospitals, general practices, clinical departments and specialist clinics. The main normative provisions in this European Prestandard are expressed i

41、n clauses 4 and 5 and apply to the General Message Descriptions (GMDs), clause 7. The symbols used in this Prestandard have the meaning as defined in normative Annex A for the purposes of this Prestandard only. Informative Annex B provides additional explanation to the General Message Descriptions.

42、Informative Annex C gives a number of example scenarios of message use. A supplementary document to this pr-ENV, called “Generic EDIFACT message implementation guide”, provides in its first chapters the method and conformance information on how the EDIFACT messages meet the requirements of the Gener

43、al Message Descriptions of the pr-ENV.ENV12538:1997 6 BSI 06-1999 1 Scope This European Prestandard specifies general messages for electronic information exchange between computer systems used by healthcare parties requesting specialist services or receiving reports from specialist service departmen

44、ts. 1.2 Examples of requests for healthcare specialty services include: referral of a patient from a GP to a hospital clinical specialist; referral of a patient for direct entry for an open access procedure; referral of a patient for direct entry onto an operation waiting list; referral of a patient

45、 for emergency hospital admission (acute referral); referral of a patient for treatment by a paramedical specialist; referrals within a hospital from one specialist to another (tertiary referral); referrals between hospitals or GPs and a community health service provider. 1.3 Examples of reports of

46、healthcare specialty services include: issue of a report including the planned action and information relating to appointment and patient transport arrangements; issue of a preliminary discharge report following a patients admission to hospital; issue of a final discharge report following a patients

47、 admission to hospital; issue of report arising from a single out-patient attendance by a patient (this may be considered to include attendance at a daycare facility); issue of a report summarising a series of out-patient attendances; issue of a report giving information about a patient when no imme

48、diate patient contact occurred (for example, to communicate the result of investigations that were not available at the time of an earlier report, or to make suggestions about treatment when no direct treatment occurred); notification of a referral by one specialist to another specialist (tertiary r

49、eferral notification); notification of the admission of a patient to hospital; notification of the death of a patient in hospital. 1.4 The messages are also applicable to modifications or cancellations of previously issued requests or reports. 1.5 While the messages specified in this European Prestandard may convey clinical and administrative information concerning patients, the way in which this information is treated in this European Prestandard does not c