ASTM E2457-2007(2013) Standard Terminology for Healthcare Informatics《保健信息学的标准术语》.pdf

1、Designation: E2457 07 (Reapproved 2013) An American National StandardStandard 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

2、 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. Scope*1.1 This terminology is intended to name and document theprincipal concepts, and their associated terms, that are uti

3、lizedin the healthcare information 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

4、will identifyalternate accepted 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 impr

5、ove the quality andmanagement 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

6、 use throughout health-care. A 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

7、 this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory limitations prior to use.2. Referenced Documents2.1 ASTM Standards:2E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems forElectro

8、nic Health Record (EHR) SystemsE1284 Guide for Construction of a Clinical Nomenclaturefor Support of Electronic Health Records (Withdrawn2007)3E1384 Practice for Content and Structure of the ElectronicHealth Record (EHR)E1633 Specification for Coded Values Used in the ElectronicHealth RecordE1762 Gu

9、ide for Electronic Authentication of Health CareInformationE1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE1985 Guide for User Authentication and AuthorizationE1986 Guide for Information Access Privileges to He

10、althInformationE1987 Guide for Individual Rights Regarding Health Infor-mation (Withdrawn 2007)3E2087 Specification for Quality Indicators for ControlledHealth Vocabularies (Withdrawn 2009)3E2147 Specification for Audit and Disclosure Logs for Usein Health Information Systems2.2 CEN Standards:4EN-12

11、017 Medical Informatics Vocabulary (MIVoc)EN-12264 Categorical Structure of Syntax of ConceptsModel for Representation of Semantics (MOSE)2.3 ISO Standards:5ISO 704 Principles and Methods of TerminologyISO/DIS 860 International Harmonization of Concepts andTermsISO/DIS 1087-1 TerminologyVocabularyPa

12、rt 1 Theoryand ApplicationISO/DIS 1087-2 TerminologyVocabularyPart 2 Com-puter ApplicationsISO 2382/4 Information TechnologyVocabularyOrganization of DataISO 10241 TerminologyStandards Representation andLayoutISO 12200 TerminologyComputer ApplicationsMachine Readable Terminology Interchange Format1T

13、his terminology is under the jurisdiction 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

14、 as E2457 07. DOI:10.1520/E2457-07R13.2For 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 vers

15、ion of this historical standard is referenced onwww.astm.org.4Available from European Committee for Standardization (CEN), 36 rue deStassart, B-1050, Brussels, Belgium, http:/www.cenorm.be.5Available from American National Standards Institute (ANSI), 25 W. 43rd St.,4th Floor, New York, NY 10036, htt

16、p:/www.ansi.org.*A Summary of Changes section appears at the end of this standardCopyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States1ISO/IEC 12207 Life Cycle ProcessesISO 12620 TerminologyComputer ApplicationsDataCategoriesISO 15188 Proje

17、ct 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 Nomenclatures in Medi

18、cine: 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 terms used in standar

19、ds 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 the healthcare sec

20、tor. 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 consensual agreement to

21、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 system used to classify

22、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 12200, GALEN). The codi

23、ngscheme 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 used for vocabulary i

24、n 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.designationrepresentation of a c

25、oncept 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 languagelanguage for special

26、 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).terminologyset of terms belongi

27、ng 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 to be used in data

28、interchange 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 entitiesand their attri

29、butes 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 defined concept and wh

30、ich 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:ANSI HITSPAmerican National Standards Institute HealthInformation Technology Standa

31、rds PanelCENCommittee European NormalizationHL7Health Level SevenISOInternational Standards OrganizationSDOStandards Developer Organization5. Classification Schema5.1 The rationale for placement of healthcare informaticsterms within an existing schema involves combination ofconcepts given in EN-1201

32、7 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 locationsof these insertions are shown as follows:EN 12017 classification shown in ( )Extensions to UMLS Semantic Type in BoldE2457 07 (2013)2A. Entity2. Conceptu

33、al entity1. Idea or Concept2. Finding3. Organism Attribute4. Intellectual Product5. Language6. Occupation or Discipline1. Biomedicine Occupation or Discipline2. Professional, Service, Administrative, Agricultural or ManufacturingOccupation7. Organization (1.2.3)1. Healthcare related organization1. H

34、ealthcare-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. Healthcare Facility2. Professional Society3. Self-help or relief organization4. Healthcare party (1.2.4)1. Laboratory service provider (1.2.4.1)2. Laborato

35、ry 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. Professional License6. Healthcare Enterprise (1.2.7.1)1. Healthcare enterprise constituencies (1.2.7.1.1)2. Healthcare enterprise dimensions (1.2.7.1.

36、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. Professional or Occupational Group1. Healthcare Players (1.2)1. Healthcare professionals (1.2.2)1. Healthcare practitioner (1.2.2.1)2. Healthcare workers2

37、. Population3. Family4. Age5. Patient or Disabled Group1. Individual Patient10. Resources (1.3)1. Healthcare Informatics (1.3.1)1. Health Information Technology (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.

38、 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. 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 Modifi

39、er (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 (2.1.2.2)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 Securit

40、y (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 Integrity (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 ac

41、cess (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 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)

42、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. Healthcare 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)

43、2. Therapeutic/Preventive Procedure1. Surgical Deed (1.1.1.2)2. Nursing Procedure (1.1.1.3)3. Administrative service4. Clinical Service2. Ancillary Service (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. Q

44、uality assurance (1.1.4)2. Research Activity3. Governmental or Regulatory Activity4. Educational Activity2. Phenomenon or Process1. Anthropogenic phenomenon2. Natural phenomenon1. Biologic Function1. Physiologic Function2. Pathologic Function6. Terms and Definitions: Current Elected Terms6.1 Annex A

45、1 contains the entries currently elected by thesubcommittees of ASTM Technical Committee E31 and sub-mitted to other SDOs of the ANSI HITSP. 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

46、 number of terms come from the CENStandard EN-12017 MIVOC.7. Terms and Definitions: Candidate Terms7.1 Annex A2 includes that list of candidate terms (withoutdefinitions) for which full consensus has not yet been reachedbut which are widely used either in the elected or alternateforms. Continuing wo

47、rk 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 beE2457 07 (2013)3transferred to Annex A1. Terms are further classified inAppendix X1 by the taxonomy given in 4.1.8. Keywords8.1 health

48、care information domain; health informatics; ter-minology; vocabularyANNEXES(Mandatory Information)A1. ELECTED TERMSACCESS(1) Possibility to retrieve medical information stored in a database or remote application. Access should be limited by security authentication mechanisms.(2) The provision of an

49、 opportunity to approach, inspect, review, retrieve, store, communicate with or make use of health information system resources (forexample, hardware, software, systems or structure) or patient identifiable data and information, or both. E1869Source 3ACCESS CONTROLPrevention of use of a resource by unidentified or unauthorized entities or both. adapted from CEN/TC-251 directorySource 2ACCESS CONTROL LISTPiece of access control information, associated with a target, which specifies the initiators who may access some target.Source 16ACCOUNTABI