BS EN ISO 1828-2012 Health informatics Categorial structure for terminological systems of surgical procedures《健康信息学 外科手术的术语系统用范畴结构》.pdf

1、raising standards worldwideNO COPYING WITHOUT BSI PERMISSION EXCEPT AS PERMITTED BY COPYRIGHT LAWBSI Standards PublicationBS EN ISO 1828:2012Health informatics Categorial structure for terminological systems of surgical proceduresBS EN ISO 1828:2012 BRITISH STANDARDNational forewordThis British Stan

2、dard is the UK implementation of EN ISO 1828:2012. It supersedes BS EN 1828:2002, which is withdrawn.The UK participation in its preparation was entrusted to T e c h n i c a l C o m m i t t e e I S T / 3 5 , H e a l t h i n f o r m a t i c s .A list of organizations represented on this committee can

3、 be obtained on request to its secretary.This publication does not purport to include all the necessary provisions of a contract. Users are responsible for its correct application. The British Standards Institution 2012. Published by BSI Standards Limited 2012.ISBN 978 0 580 68909 3 ICS 35.240.80 Co

4、mpliance with a British Standard cannot confer immunity from legal obligations.This British Standard was published under the authority of the Standards Policy and Strategy Committee on 30 September 2012.Amendments issued since publicationDate T e x t a f f e c t e dEUROPEAN STANDARD NORME EUROPENNE

5、EUROPISCHE NORM EN ISO 1828 September 2012 ICS 35.240.80 Supersedes EN 1828:2002English Version Health informatics - Categorial structure for terminological systems of surgical procedures (ISO 1828:2012) Informatique de sant - Structure catgorielle pour les systmes terminologiques des interventions

6、chirurgicales (ISO 1828:2012) Medizinische Informatik - Kategoriale Struktur fr Klassifikationen und Kodierungssysteme fr chirurgische Prozeduren (ISO 1828:2012) This European Standard was approved by CEN on 14 September 2012. CEN members are bound to comply with the CEN/CENELEC Internal Regulations

7、 which stipulate the conditions for giving this European Standard the status of a national standard without any alteration. Up-to-date lists and bibliographical references concerning such national standards may be obtained on application to the CEN-CENELEC Management Centre or to any CEN member. Thi

8、s European Standard exists in three official versions (English, French, German). A version in any other language made by translation under the responsibility of a CEN member into its own language and notified to the CEN-CENELEC Management Centre has the same status as the official versions. CEN memb

9、ers are the national standards bodies of Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portug

10、al, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and United Kingdom. EUROPEAN COMMITTEE FOR STANDARDIZATION COMIT EUROPEN DE NORMALISATION EUROPISCHES KOMITEE FR NORMUNG Management Centre: Avenue Marnix 17, B-1000 Brussels 2012 CEN All rights of exploitation in any form and by any

11、 means reserved worldwide for CEN national Members. Ref. No. EN ISO 1828:2012: EBS EN ISO 1828:2012 EN ISO 1828:2012 (E) 3 Foreword This document (EN ISO 1828:2012) has been prepared by Technical Committee CEN/TC 251 “Health informatics“, the secretariat of which is held by NEN, in collaboration wit

12、h Technical Committee ISO/TC 215 “Health informatics“. This European Standard shall be given the status of a national standard, either by publication of an identical text or by endorsement, at the latest by March 2013, and conflicting national standards shall be withdrawn at the latest by March 2013

13、. Attention is drawn to the possibility that some of the elements of this document may be the subject of patent rights. CEN and/or CENELEC shall not be held responsible for identifying any or all such patent rights. This document supersedes EN 1828:2002. According to the CEN/CENELEC Internal Regulat

14、ions, the national standards organisations of the following countries are bound to implement this European Standard: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Ital

15、y, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and the United Kingdom. BS EN ISO 1828:2012ISO 1828:2012(E) ISO 2012 All rights reserved iiiContents PageForeword ivIntroduction v1 Scope 12 Normative refer

16、ences . 13 Terms and definitions . 14 Description of categorial structure for terminological systems of surgical procedures 54.1 General . 54.2 Goal of the terminological system for which the categorial structure is set 54.3 Categories . 54.4 List of the representations of relations 55 Domain constr

17、aint requirements 56 UML (Unified Modeling Language) Diagram 6Annex A (informative) Definitions from ISO 17115:2007, 2.7, Terminological systems . 8Annex B (informative) Categorial structures of the most recent and/or more widespread terminological systems (in use or in progress) of surgical procedu

18、res 9Annex C (informative) Excerpt of EN 15521:2007 giving definitions of the entities of the category human anatomy (see 3.8.2) . 11Bibliography .14BS EN ISO 1828:2012ISO 1828:2012(E)ForewordISO (the International Organization for Standardization) is a worldwide federation of national standards bod

19、ies (ISO member bodies). The work of preparing International Standards is normally carried out through ISO technical committees. Each member body interested in a subject for which a technical committee has been established has the right to be represented on that committee. International organization

20、s, governmental and non-governmental, in liaison with ISO, also take part in the work. ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of electrotechnical standardization.International Standards are drafted in accordance with the rules given in the IS

21、O/IEC Directives, Part 2.The main task of technical committees is to prepare International Standards. Draft International Standards adopted by the technical committees are circulated to the member bodies for voting. Publication as an International Standard requires approval by at least 75 % of the m

22、ember bodies casting a vote.Attention is drawn to the possibility that some of the elements of this document may be the subject of patent rights. ISO shall not be held responsible for identifying any or all such patent rights.ISO 1828 was prepared by the European Committee for Standardization (CEN)

23、Technical Committee CEN/TC 251, Health informatics, in collaboration with ISO Technical Committee ISO/TC 215, Health informatics, in accordance with the agreement on technical cooperation between ISO and CEN (Vienna Agreement). The preparation of this International Standard brought to light an urgen

24、t need to review the family of terminological standards ISO 704, ISO 1087, ISO 17115 and EN 12264 in order to clarify the relations between concept, generic concept, specific concept, object, class, instance, designation and formal representation. This also applies to the forthcoming edition of ISO/

25、TR 24156 (all parts).iv ISO 2012 All rights reservedBS EN ISO 1828:2012ISO 1828:2012(E)IntroductionThe driving factor behind this International Standard is the fact that terminological systems for surgical procedures are used for a wide range of purposes. Some of the main applications include, for i

26、nstance, being incorporated as an integral part of a computerized health care record for use in discharge summary information, for clinical research, peer review, quality assurance, reimbursement, workload assessment, resource management, utilization comparisons, public health management and epidemi

27、ological surveys. Unlike diagnoses, for which the International Classification of Diseases (ICD) is an accepted de facto standard, there are at least as many coding systems for surgical procedures as there are developed countries and, very often, several such coding systems for different usages or f

28、or different surgical disciplines in each country. On the other hand, most of the countries are unable to satisfy such applications for they lack such terminological systems or use terminological systems from other countries. This hampers the exchange of meaningful health information, for instance f

29、or international statistical comparisons.Five types of health care terminological systems are defined in ISO 17115: classifications, coding scheme, coding systems, reference terminologies and clinical terminologies.Defining a surgical procedure is considered difficult because there are neither speci

30、fic criteria to define it nor specific criteria to define the limit between what a surgical procedure is and what it is not.Within this International Standard, terminological systems of surgical procedures are defined in the following way: In this International Standard, a terminological system of s

31、urgical procedures is considered to have been defined as such by its owner/developer in order to cover surgical procedures. The owner/developer decides what can be considered a surgical procedure and then defines the content of the terminological system.Terminological systems for surgical procedures

32、 group the different types of terminological systems including terminological systems defined by ISO 17115:2007, 2.7: classifications, coding scheme, coding systems, reference terminology and clinical terminology.ENV 1828:1995 started by identifying the categories of terms in existing procedure clas

33、sifications within and outside Europe and also the natural language used in surgical reports. It defined the categorial structure which contains the definition of a set of categories of terms and the internal relations that combine them into a conceptual system.EN 1828:2002 has been widely tested an

34、d/or applied in national and European projects (The Nordic NCSP, the French CCAM, for the revision of UK OPCS and by three German-speaking countries (Austria, Germany and Switzerland) as well as outside Europe in Australia (ACHI and ICHI) and Canada (CCI).EN 1828:2002 was based on the assessment of

35、different existing health care terminological systems. They are made available in the bibliography as the material on which the standard was based. The main terminological systems of surgical procedures developed since that edition of the standard have been added as well.WHO-FIC (World Health Organi

36、zation Family of International Classification) are currently implementing a project called ICHI (International Classification of Health Intervention) which is intended to be based on a concept system that is conformant to this International Standard. SNOMED CT IHTSDO has planned to align the surgica

37、l procedures within SNOMED CT with this International Standard.International standardization efforts by CEN and ISO related to electronic health records and semantic interoperability have resulted in a number of categorial structures which are a step towards supporting health care terminological sys

38、tems with a full concept system or ontology that in turn will support multiple uses and safe communication. In the present categorial structure standard, several of the definitions of basic terms related to categorial structures have been updated to comply with the most recent edition of ISO 17115.

39、This is the first revision of a categorial structure standard developed by CEN or ISO since 1995, and one of several that are to be reviewed in the next five years. These revisions are being processed in collaboration between CEN/TC 251 and ISO/TC 215. ISO 2012 All rights reserved vBS EN ISO 1828:20

40、12BS EN ISO 1828:2012Health informatics Categorial structure for terminological systems of surgical procedures1 ScopeThis International Standard specifies the minimal characteristics of a categorial structure for terminological systems of surgical procedures and the minimal domain constraints to sup

41、port interoperability, comparability and the exchange of meaningful information on surgical procedures, independently of the language, insofar as the significant differences are specified by the system.NOTE 1 Further characteristics or more detailed value sets can be used for specific purposes.NOTE

42、2 Categorial structures support interoperability by providing common frameworks within which to develop terminological systems that can be related to each other, and to analyse the properties of different terminological systems in order to derive relationships between them.This International Standar

43、d is applicable to terminological systems of surgical procedures in all surgical disciplines. It covers only the terminology part, as defined in ISO 1087-1:2000, of the terminological systems of surgical procedures.It is intended to be used by: organizations involved with the development or maintena

44、nce of terminological systems for surgical procedures, namely for multipurpose terminological systems on a national or international level; organizations developing and maintaining software tools that allow natural clinical language expressions analysis, generation and mapping to the main existing t

45、erminological systems of surgical procedures.This International Standard is intended to be used as an integrated part of computer-based applications and for electronic health care records. It is of limited value for manual use. This International Standard is not suitable for, nor intended for use by

46、, individual clinicians or hospital administrators. It is not the purpose of this International Standard to standardize the end user terminological system or to conflict with the concept systems embedded in national practice and languages.2 Normative referencesThe following referenced documents are

47、indispensable for the application of this document. For dated references, only the edition cited applies. For undated references, the latest edition of the referenced document (including any amendments) applies.EN 12264, Health informatics Categorial structures for systems of concepts3 Terms and def

48、initionsFor the purposes of this document, the following terms and definitions apply.3.1categorial structureminimal set of domain constraints for representing health care terminological systems entities in a precise subject field to achieve a precise goalNOTE Adapted from ISO 17115.INTERNATIONAL STA

49、NDARD ISO 1828:2012(E) ISO 2012 All rights reserved 1BS EN ISO 1828:2012ISO 1828:2012(E)3.2domain constraintrule prescribing the set of representations of relations that are valid to specialize a category in a certain domainNOTE Adapted from ISO 17115.3.3categorytype of entity shared by all the individual instances in existence in the present, past and futureEXAMPLE The category “liver” is instantiated by this liver and all individual livers in existence in the present, past and future.NOTE 1 Categories may be more or less general. Where one category is