ENV 12539-1997 en Medical Informatics - Request and Report Messages for Diagnostic Service Departments《医疗信息学 诊断服务站用要求通知和结果通知》.pdf

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1、Medical informatics - Request and report messages for diagnostic service departments it it vi ICs 11.040.50; 35.240.70 DD ENV 12539:1998 NO COPYING WITHOUT BSI PERMISSION EXCEPT AS PERMITTED BY COPYRIGHT LAW _- - STD.BSI DD ENV 12539-ENGL 1978 1b24bb9 0738bb5 849 U having been prepared under the dir

2、ection of the DISC Board, was published under the authority of the Standards Committee and comes into effect on 15 November 1998 Amd. No. O BSI 1998 ISBN O 680 30628 7 DD ENV 12639:1998 Date National foreword This Draft for Development is the English language version of ENV 12539: 1997. This publica

3、tion is not to be regarded as a British Standard. It is being issued in the Draft for Development series of publications and is of 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 p

4、ractical application may be obtained. Comments arising kom the use of this Draft for Development are requested so that UK experience can be reported to the European organization responsible for its conversion into a European Standard. A review of this publication will be initiated 2 yem after its pu

5、blication by the European organization so that a decision can be taken on its status at the end of its threeyear life. The commencement 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

6、 Committee will decide whether to support the conversion into a European Standard, to extend the life of the prestandard or to 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

7、 document reference and clause number and proposing, where possible, an appropriate revision of the text. A list of organizations represented on this committee can be obtained on request to its secretary. Cross-references The British Standards which implement international or European publications r

8、eferred to in this document may be found in the BSI Standards Catalogue under the section entited “International Standards Correspondence 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, th

9、e ENV title page, pages 2 to 186, an inside back cover and a back cover. This Draft for Development, Amendments issued since publication Text affected EUROPEAN PRESTANDARD PRNORME EUROPEENNE EUROPISCHE VORNORM ENV 12539 March 1997 ICs 11.040.50; 35.240.70 Descriptors: medicine, diagnosis, data proce

10、ssing, information interchange, data transfer English version Medical informatics - Request and report messages for diagnostic service departments Informatique de sant - Messages de demandes et de comptes rendus de service de diagnostic Medizinische Informatik - Anforderungs- und Ergebnismitteilunge

11、n fr diagnostische Dienstleistuigsstellen This European Prestandard (ENV) was approved by CEM on 1997-02-09 as a prospective standard for provisional application. lhe period of validity of this ENV is limited initially to three years. After two years the members of CEN will be requested to sutmit th

12、eir torments, particularly on the question whether the ENV can be converted into an European Standard (EN). CEN members are requircd to amunce the existence of this ENV in the sem way as for an EN and to make the ENV available pronptly at national level in an appropriate form. It is permissible to k

13、eep conflicting national standards in force (in perallel to the ENV) until the final decision about the pssible conversion of the ENV into an EN is reached. CEM n#mbers are the national standards bodies of Austria, Belgiun, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembou

14、rg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and United Kingdom. CEN European Conmittee for Standardization Comit Europen de Normalisation Europisches Komi tee fr Norm9 Central Secretariat: rue de Stssart,36 8-1050 Brussels 0 1997 Copyright reserved to CEN members Ref. No. ENV 12539

15、:1997 E STD-BSI DD EN 12539-ENGL 1998 H Lb24bb9 0738bb7 bLL H Page 2 ENV 12539:1997 TABLE OF CONTENTS FOREWORD 3 INTRODUCTION 4 1 . SCOPE 6 2 . NORMATIVE REFERENCES 8 3 . DEFINlTiONS AND ABBREVIATIONS 9 4 . REQUIREMENTS 13 5 . COMMUNICATION ROLES AND SUPPORTED SERVICES 14 5.1 General . 14 5.2 Messag

16、e groups . 14 5.3 Communication roles 14 5.4 Communication roles and Generai Message Descriptions 15 5.5 Communication roles and mpported services 16 5.6 Message origination mes . 16 18 6.1 Introduction 18 6.2 Domain information Model diagrams . 19 6.3 Textual description of the objecta, their relat

17、ionships and attributes . 24 6 . DOMAIN INFORMATION MODEL 6.4 Textuai descriptions of common attribute groups . 66 69 7.1 introduction 69 7.2 New diagndc service request GMD 70 7.3 Diagnostic service request modification GMD 81 7.4 Diagaostic service request cancellation G. . 90 7.5 New diagnostic s

18、ervice report GMD 93 7.6 Dirgndc acrvicc report modification GMD 102 7.7 Diagnostic service report cancellation GMD . 112 7.8 New diagnostic service plan report GMD 114 7.9 Diagnostic service plan report madification GMD 121 7.10 Attribute layer 128 155 A1 Modei componen. . 155 112 Symbols 155 A3 No

19、tes . 157 A4 Hierarchicil Gs . 158 B . ANNEX B : RELATING THE MODELS TO ACTAL REQUESTS AND REPORTS (INFORMATIVE) 160 B.1 introduction . 160 B.2 Requesting diagwstic services 160 B.3 Reporting the results of diagnostic investigations . 164 B.4 Reporting the planning or progresa of diagnostic service

20、. 167 169 C.1 Summary of the scenarios 169 C.2 Request rcenan os . 169 C.3 Report scen uios . 175 C.4 Illustntions ofthe different data types in a report 176 C.5 Acceptance, progress reporting and followup scenarios . 181 C.6 Scenarios specific to post-mortem JtPdies . 182 C.7 Diagnostic services th

21、at involve two or more diagnostic service departments . 183 7 . GENERAL MESSAGE DESCRIPTIONS A. ANNEX A : HOW TO READ THE MODELS (NORMATWE) C . ANNEX C . SCENARIOS (INFORMATIVE) INDEX 184 _ STD.BS1 DD ENV L2537-ENGL 1998 LbZYbbS 0738bbB 558 Page 3 ENV 12539:1997 This European Prestandard has been pr

22、epared by Technical Committee CEN/TC 251 Medicai idonnatics”, the secretariat of which is held by IBN. According to the CENXENELEC Internal Regulations, the national standards organisations of the foiiowing countries are bound to announce this European Prestandard: Austria, Belgium, Denmark, Finland

23、, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom. STD.BSI DD ENV 12537-ENGL 1978 Iy 1b24bb9 0738bb9 494 m Page 4 EMT 12539:1997 INTRODUCTION The increased use of data processing and telecommunications cap

24、abilities has made possible the interchange of information in machine readable and machine prossable formats. As automated interchange of information in heaithcare increases, it is essential to provide appropriate standards. Computer systems are used for the storage and pracessing of information in

25、many diagnostic service departments. Many of those asking for and receiving resuits of investigations also use computer systems to store and process patient reiatcd information. This information includes details of investigations requested and results received. Diagnostic seMce departments carry out

26、 investigations quested by healthcue parties and send he results of these investigations to requesters and sometimes to other healthcare parties. Electronic rauser of requests and results, reduces the need for manual data entry and the risic of transcription errors. It also resuits in greater effici

27、ency, leading to better Mthcare prwision. Standards are requited to facilitate electronic transfer of requests for, and results of, investigations between the many systems currently used. implementation of this European Presandard will therefore : hciiitate the electronic Wer of orders for diagnhc s

28、ervices from questing hdthcare parties, to diagnostic sexvi departments; iacilitate the electronic transfer of reports from diagnostic service departments to requesters and other healthcare parties; reduce the need for human intervention in information interchange between applications uscd by diagno

29、stic service deparumnts and those uscd by other healthcue parties; minimise the time and effort required for the introduction of information interchange agreements; reduce the development effort required by suppliers to allow communication between a wide range of applications in this field; reduce t

30、he cost of information interchange between diagnostic senice departments and paries requesting diagnostic service department seMces. When implementing information exchange based on this European hestandard, data security sexvices including condcntiaiity provisions must be ensured according to the la

31、ws actually in force in the different CEN member countries. The method by which this European prestandard has been developed is based on the recommmendations of the CEN Report “Investigation of Syntaxes for Exisng Interchange Formats to be used in Healthcare“ (CR 1350:1993). Extensions to the method

32、, proposcd by CEN TC251 T3-025 while this document was being drafted, have also been applied where possible and relwant. This standard is intended for use by message developers. Its provisions are directly dewant to suppliers of computer systems for use in diagnostic service departments, hospitals,

33、general practices, clinical departments and specialist clinics. Its provisions are ais0 relevant to those planning, spacifying, procuring or implementing information systems for use in diagnostic service departments, hospitals, general practices, clinical departments and specialist clinics. The main

34、 normative pmisions in this European Prestandard are expressed in clauses 4 and 5 and apply to the Generai Message Descriptions (GMDs), clause 7. The symbols used in this -dard have the meaning as defined in normative annex A for the purposes of this Prestandard only. Informative annex B explains ho

35、w the Domain Information Model relates to actual requests and reports. Informative annex C gives a number scenarios as examples of message use. Page 5 ENV 12539:1997 A supporting doniment to this ENV entitied “Generic EDIFACT message implementation guide for diagnostic service requesi and report mes

36、sages“ is being prepared. This will contain message definitions using the EDIFACT (Electronic data interchange for administration, commerce and transport) stanard IS0 9735, in lhe with the procedures for submission of EDIFACT-based standards of the UNECE. These message defrnitions wiil be implementa

37、ble Message Speafcations (IMSs) conforming with this European Prestandard. The Supporting document will also contain message implementation guidelines for these messages. They should be considered an essential component of the 1MS providing a generic EDFACT implementation specification for use in Eu

38、rope. The supporting document will be submitted to CEN for ballot as a CEN Report. The EDIFACT message definitions that it cuntains wiil also be submitted to the UNECE as a proposai for a UNted Nations Siandard Message (UNSM). Arrangements between CEN and the Western European EDIFACT Board ensure th

39、at UNS - NuCl= mediCine; - Ultrasound; - ther imaging techniques (e.g. magnetic resonance tomography); - Electrophysiology; - Physiological function tests; - Diagnostic audiology; - Cytoiogy; - Anatomic pathology; - Histopathology; and - Post-mortem studies (autopsies). The messages specified also a

40、llow the inclusion of clinical obsewations about the patient where these are required to perform or intepnt the results of these studies. 1.3 This European Presandard is not applicable to messages requesting or reporting on the results of diagnostic laboratory specialties already covered by ENV 16 1

41、3: - Clinical Chemistry; - Clinical Biochemistry; - Clinical Immunology; - Immunohematology; - Clinical Microbiology (including Bacteriology, Mycology, Parasitology and Virology). - TOXCOOY; - Haematology; 1.4 This European Presandard is not applicable to messages requesting or reporting on blood tr

42、ansfusion services. 1.5 This European Prestandard does not spec the manner in which diagnostic ScM? department seMces are divided between specialties as this varies in accordance wih different national and local practices. 1.6 The messages specified by this European Presandard, supplement those spec

43、ied in other related sandards, such as ENV1613. In some borderline Situations more than one member of this family of sandards may meet the requirements. In these circumstances, the decision as to which messages are applicable to particular departments or studies in particular healthcare environments

44、 should be agreed by communicating parhes. 1.7 The scope of the messages specified by this European Presandard, comprises requests and results related to investigations carried out by diagnostic service departments on patients. This European Presandard is applicable whether the healthcare party comm

45、unicating with the diagnostic seMce department is a person (such as a doctor or other healthaxe professional) or an organisation (such as a hospital, clinic or department). A diagnostic service department may itself act as the healthcare party submitting requests to, or receiving results from other

46、diagnostic service departments. However, this European Prestandard has not been developed to meet the needs of messages that are specic to communications between one diagnostic service department and another. Page 7 ENV 12539:1997 1.8 This European Restandard is applicable to requests for diagnostic

47、 services to be performed on: - patients; - samples, obtained from a patient, submitted to the diagnostic service department by the requester; - samples that are to be obtained, from a patien, by the diagnostic department in response to a request for an - materials or ixormation resulting from a pre

48、vious diagnostic setvice (e.g. a second opinion on Nms from a previous It is also applicable to modifications or cancellations of previously issued requests. investigation; diagnostic service procedure). 1.9 This European prestandard is applicable to reports of the results of diagnostic services. Th

49、e report message it spccifes supports the communication of partiai, supplementary, complete and cumulative reports. It is also applicable to modifications and cancellations of previously issued reports. 1.10 This European Prtstandard permits diagnostic service report messages to be sent whether or not a diagnostic seMce request message bas been received. 1.1 1 This European prcstandard also specifies diagnosic service plan report messages. These may be sent before a diagnostic service has been underiaken to communicate information a