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

1、Designation: E2457 07 (Reapproved 2013)Standard Terminology forHealthcare Informatics1This standard is issued under the fixed designation E2457; 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

2、 parentheses indicates the year of last reapproval. Asuperscript epsilon () 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 informa

3、tion domain and 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 accepte

4、d terms for the 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

5、of all facets of 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

6、 separate process from this standard that is described inISO 15188 will manage the approval of biomedical andhealthcare 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 ap

7、pro-priate safety and health practices and determine the applica-bility of regulatory limitations prior to use.1.3 This international standard was developed in accor-dance with internationally recognized principles on standard-ization established in the Decision on Principles for theDevelopment of I

8、nternational Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers to Trade (TBT) Committee.2. Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectronic Hea

9、lth Record (EHR) Systems (Withdrawn2017)3E1284 Guide for Construction of a Clinical Nomenclaturefor Support of Electronic Health Records (Withdrawn2007)3E1384 Practice for Content and Structure of the ElectronicHealth Record (Withdrawn 2017)3E1633 Specification for Coded Values Used in the Electroni

10、cHealth Record (Withdrawn 2017)3E1762 Guide for Electronic Authentication of Health CareInformation (Withdrawn 2017)3E1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health Records (Withdrawn 2017)3E1985 Guide for User Authent

11、ication and Authorization(Withdrawn 2017)3E1986 Guide for Information Access Privileges to HealthInformation (Withdrawn 2017)3E1987 Guide for Individual Rights Regarding Health Infor-mation (Withdrawn 2007)3E2087 Specification for Quality Indicators for ControlledHealth Vocabularies (Withdrawn 2009)

12、3E2147 Specification for Audit and Disclosure Logs for Usein Health Information Systems (Withdrawn 2017)32.2 CEN Standards:4EN-12017 Medical Informatics Vocabulary (MIVoc)EN-12264 Categorical Structure of Syntax of ConceptsModel for Representation of Semantics (MOSE)1This terminology is under the ju

13、risdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.35 onHealthcare Data Analysis.Current edition approved March 1, 2013. Published March 2013. Originallyapproved in 2006. Last previous edition approved in 2006 as E2457 07. DOI:10.1520/E2457

14、-07R13.2For 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.3The last approved version of this historical standard

15、 is referenced onwww.astm.org.4Available from European Committee for Standardization (CEN), 36 rue deStassart, B-1050, Brussels, Belgium, http:/www.cenorm.be.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Consho

16、hocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization established in the Decision on Principles for theDevelopment of International Standards, Guides and Recommendations issued by the World Trade Orga

17、nization Technical Barriers to Trade (TBT) Committee.12.3 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 Appli

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

19、riesISO 15188 Project Management Guidelines for TerminologyInterchange Format2.4 Other Documents:American National Standard Dictionary of InformationTechnology (ANSDIT) http:/www.incits.orgCEN PrENV 11994 Medical Informatics VocabularyGALEN GeneralizedArchitecture for Language, Encyclope-dias and No

20、menclatures in Medicine: Univ. of ManchesterIEEE 610.5 Glossary of Data ManagementUnified Medical Language System (UMLS) KnowledgeSources National Library of Medicine 7th ExperimentalEdition January 19963. Significance and Use3.1 This standard vocabulary is intended to be used as areference about te

21、rms used in standards for healthcare infor-matics and in general discussions about informatics issuesrelating to the healthcare sector, including: clinical care,resource management, policy, clinical or health services re-search or biomedical research in basic or applied areas ofscience that refer to

22、 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 fact that there is consensus agreementon the usage of a particular form rather than an imposition.This conse

23、nsual 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 accordance with ISO/DIS 1087-1, ISO 704,ISO 12620, and EN-12017, ISO/DIS 860, EN-12264, andANSDIT.3.2 The syste

24、m 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 drawn on the terms used in bothEN-12017 and in UMLS for biomedicine (Guide E1284,Specification E1633, ISO 1220

25、0, 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 theNational Library of Medicine.4. Terminology4.1 Vocabulary about VocabularyThis section lists thoseterms us

26、ed 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 1087-1 Terms:admitted termterm accepted as a synonym for a preferredterm by an authoritative body.designationre

27、presentation 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 subjectfield and their designations.preferred termterm recommended by an authoritative body.special languagel

28、anguage for special purposes.technical dictionarydictionary of terminologic entries ordesignation-related information, from one or more specificsubject fields.termdesignation consisting of one or more words whichdenote a given concept in a special language (language forspecial purposes).terminologys

29、et 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 to This Standard:candidate termthat form which has been submitted to thereference body for election as that

30、 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 considered indivisible and in other contexts may consist ofdata items; and (2) a named identifier of each of the enti

31、tiesand their attributes that are represented in a database. ANSIX3.172-1990data itemnamed component of a data element; usually thesmallest component. ANSI X3.172-1990data valueinstance of a data item. ANSI X3.172-1990elected termthat form which is rapidly and fully understoodas representing the def

32、ined 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 particular profession orsubject area.4.4 Acronyms:5Available from American National Standards Institute (ANSI), 25

33、 W. 43rd St.,4th Floor, New York, NY 10036, http:/www.ansi.org.E2457 07 (2013)2ANSI HITSPAmerican National Standards Institute HealthInformation Technology Standards PanelCENCommittee European NormalizationHL7Health Level SevenISOInternational Standards OrganizationSDOStandards Developer Organizatio

34、n5. Classification Schema5.1 The rationale 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

35、locationsof these insertions are shown 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 Discip

36、line2. Professional, Service, Administrative, Agricultural or ManufacturingOccupation7. Organization (1.2.3)1. Healthcare related organization1. 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. Healthcar

37、e Facility2. Professional Society3. 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. Prof

38、essional License6. Healthcare 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. Professi

39、onal or Occupational Group1. 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 Tech

40、nology (1.3.1.1)1. Health Information 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

41、. Terminology (2.1.1)1. Concept (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.

42、2.2)3. View (2.1.2.3)4. Modeling 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 Integri

43、ty (2.2.3.6)7. Security Audit (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

44、 Device (2.4.2)3. Electronic 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. Healthca

45、re Activity (1.1)1. Healthcare 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 Servic

46、e (1.1.1.2)3. Telemedicine (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 ProcessE2457 07 (2013)31. Anthro

47、pogenic phenomenon2. Natural phenomenon1. Biologic 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 HITS

48、P. Terms not fullyagreed upon by these bodies 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 cand

49、idate terms (withoutdefinitions) for which 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 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; vocabularyANNEXES(Mandatory Information)A1. EL