1、raising standards worldwideNO COPYING WITHOUT BSI PERMISSION EXCEPT AS PERMITTED BY COPYRIGHT LAWBSI Standards PublicationDD ISO/TS 22789:2010Health informatics Conceptual framework forpatient findings and problemsin terminologiesDD ISO/TS 22789:2010 DRAFT FOR DEVELOPMENTNational forewordThis Draft
2、for Development is the UK implementation of ISO/TS22789:2010.This publication is not to be regarded as a British Standard.It is being issued in the Draft for Development series of publicationsand is of a provisional nature. It should be applied on thisprovisional basis, so that information and exper
3、ience of its practicalapplication can be obtained.Comments arising from the use of this Draft for Developmentare requested so that UK experience can be reported to theinternational organization responsible for its conversion toan international standard. A review of this publication willbe initiated
4、not later than 3 years after its publication by theinternational organization so that a decision can be taken on itsstatus. Notification of the start of the review period will be made inan announcement in the appropriate issue of Update Standards.According to the replies received by the end of the r
5、eview period,the responsible BSI Committee will decide whether to support theconversion into an international Standard, to extend the life of theTechnical Specification or to withdraw it. Comments should be sentto the Secretary of the responsible BSI Technical Committee at BritishStandards House, 38
6、9 Chiswick High Road, London W4 4AL.The UK participation in its preparation was entrusted to TechnicalCommittee IST/35, Health informatics.A list of organizations represented on this committee can beobtained on request to its secretary.This publication does not purport to include all the necessarypr
7、ovisions of a contract. Users are responsible for its correctapplication. BSI 2010ISBN 978 0 580 56726 1ICS 35.240.80Compliance with a British Standard cannot confer immunity fromlegal obligations.This Draft for Development was published under the authority ofthe Standards Policy and Strategy Commit
8、tee on 30 September 2010.Amendments issued since publicationDate Text affectedDD ISO/TS 22789:2010Reference numberISO/TS 22789:2010(E)ISO 2010TECHNICAL SPECIFICATION ISO/TS22789First edition2010-06-15Health informatics Conceptual framework for patient findings and problems in terminologies Informati
9、que de sant Cadre conceptuel pour les constats des patients et les problmes de terminologies DD ISO/TS 22789:2010ISO/TS 22789:2010(E) PDF disclaimer This PDF file may contain embedded typefaces. In accordance with Adobes licensing policy, this file may be printed or viewed but shall not be edited un
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14、htiso.org Web www.iso.org Published in Switzerland ii ISO 2010 All rights reservedDD ISO/TS 22789:2010ISO/TS 22789:2010(E) ISO 2010 All rights reserved iiiContents Page Foreword iv Introduction.v 1 Scope1 1.1 Main purpose .1 1.2 Target groups 2 1.3 Topics considered outside the scope.2 2 Terms and d
15、efinitions .2 3 Conceptual framework for patient findings and problems .5 3.1 Overview.5 3.2 Sanctioned characteristics.5 4 Conformity to the Technical Specification .9 Bibliography11 DD ISO/TS 22789:2010ISO/TS 22789:2010(E) iv ISO 2010 All rights reservedForeword ISO (the International Organization
16、 for Standardization) is a worldwide federation of national standards bodies (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
17、the right to be represented on that committee. International organizations, 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. Intern
18、ational Standards are drafted in accordance with the rules given in the ISO/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. Publicati
19、on as an International Standard requires approval by at least 75 % of the member bodies casting a vote. In other circumstances, particularly when there is an urgent market requirement for such documents, a technical committee may decide to publish other types of document: an ISO Publicly Available S
20、pecification (ISO/PAS) represents an agreement between technical experts in an ISO working group and is accepted for publication if it is approved by more than 50 % of the members of the parent committee casting a vote; an ISO Technical Specification (ISO/TS) represents an agreement between the memb
21、ers of a technical committee and is accepted for publication if it is approved by 2/3 of the members of the committee casting a vote. An ISO/PAS or ISO/TS is reviewed after three years in order to decide whether it will be confirmed for a further three years, revised to become an International Stand
22、ard, or withdrawn. If the ISO/PAS or ISO/TS is confirmed, it is reviewed again after a further three years, at which time it must either be transformed into an International Standard or be withdrawn. Attention is drawn to the possibility that some of the elements of this document may be the subject
23、of patent rights. ISO shall not be held responsible for identifying any or all such patent rights. ISO/TS 22789 was prepared by Technical Committee ISO/TC 215, Health informatics. DD ISO/TS 22789:2010ISO/TS 22789:2010(E) ISO 2010 All rights reserved vIntroduction Enormous investment has occurred ove
24、r the last two decades in creating health care terminological systems. Further expansion or additions are likely. Many developments overtly or covertly share features of a common model of clinical findings. The objective of this Technical Specification is to express a core categorial structure of cl
25、inical findings based upon existing schemes including the World Health Organization ICD-10, NHS Clinical Terms Version 3, International Health Terminology Standards Development Organisations SNOMED Clinical Terms and the WONCA 2001 International Classification of Primary Care. The development of a T
26、echnical Specification will help existing users to develop a mapping or cross-walks between one scheme and another and provide a robust logical framework for construction of new areas or consistency for updated versions of existing terminological systems. The model describes the underlying principle
27、s of clinical findings and important semantic links referencing a set or sets of characterizing concepts such as anatomy and causative organisms. It utilizes ISO 17115, which has been designed to describe such patterns for concept representation in a particular domain. Within this Technical Specific
28、ation, the following notation is used: A bold notation has been used where references are made to terms defined in Clause 2. An item enclosed by single angle brackets refers to a category that can be specialized to various concepts, as required. An item enclosed within the text by single accolades i
29、dentifies a semantic link. DD ISO/TS 22789:2010DD ISO/TS 22789:2010TECHNICAL SPECIFICATION ISO/TS 22789:2010(E) ISO 2010 All rights reserved 1Health informatics Conceptual framework for patient findings and problems in terminologies 1 Scope 1.1 Main purpose The purpose of this Technical Specificatio
30、n is to specify a categorial structure, within the subject field of patient findings and problems, by defining a set of common domain constraints for use within terminological systems including a classification, coding scheme, coding system, reference terminology and clinical terminology. Clinical f
31、indings are concepts that are recorded in clinical records and can describe any state observed directly or indirectly concerning a patient and their relationship with the environment. This Technical Specification is focused on a sub-population of these findings concerning in vivo descriptions of sta
32、te (structure and function) directly related to the patient. This class of concepts includes: diseases, which may be defined as a state caused by a known or assumed pathological process impairing the normal physiological function and/or anatomical structure affecting all or part of a patient, where
33、a specific pathological change is caused by a defined mechanism; findings of state or function (including normal findings) observed directly relating to a patient. This Technical Specification describes a concept system detailing a domain constraint of sanctioned characteristics each composed of a s
34、emantic link and an applicable characterizing category. The potential uses for this conceptual framework are to: support developers of new terminology systems concerning patient findings and problems; support developers of new detailed content areas of existing terminology systems concerning patient
35、 findings and problems to ensure conformance; facilitate the representation of patient findings and problems using a standard core model in a manner suitable for computer processing; provide a conceptual framework for the generation of compositional concept representation of patient findings and pro
36、blems; facilitate the mapping and improved semantic correspondence between different terminologies by proposing a core specification for patient findings and problems; provide a core model to describe the structure of patient findings and problems, and facilitate improved semantic correspondence wit
37、h information models. DD ISO/TS 22789:2010ISO/TS 22789:2010(E) 2 ISO 2010 All rights reserved1.2 Target groups The target groups for this Technical Specification are: developers of terminology systems concerning patient findings and problems; developers of information systems that require a structur
38、ed framework of concepts to facilitate implementation; IT specialists, analysts and epidemiologists who require common models of knowledge to facilitate analysis of current and legacy data from one or more information systems; clinicians and coders to provide greater consistency in structure and org
39、anization when entering and retrieving data using one or more terminology systems; managers and administrative personnel in providing a benchmark by which to judge terminology solutions: as to whether the potential options will deliver compatibility with legacy data and future proofing to emerging t
40、erminology products. 1.3 Topics considered outside the scope Topics considered outside the scope of this Technical Specification include: a comprehensive categorial structure for clinical findings; laboratory findings (including biochemical and histological results); signal findings (including the o
41、utput from imaging and electrophysiological tests); social findings; the absence of findings, e.g. absent bowel sounds, the absence of a knee reflex, are not included within this Technical Specification as it might prejudice subsequent attempts at standardizing the modelling of such instances; an ex
42、haustive list of all possible characterizing concepts that could be used to describe clinical findings. 2 Terms and definitions For the purposes of this document, the following terms and definitions apply. 2.1 associative relation relation between two concepts (2.9) having a non-hierarchical themati
43、c connection by virtue of experience ISO 1087-1:2000, definition 3.2.23 EXAMPLE An associative relation (2.1) exists between the concepts (2.9) “education” and “teaching”, “baking” and “oven”. NOTE Other relations between concepts (2.9) are: hierarchical, generic, partitive, sequential, temporal and
44、 causal. 2.2 categorial structure minimal set of domain constraints (2.11) for representing concept systems (2.10) in a subject field ISO 17115:2007, definition 2.4.5 DD ISO/TS 22789:2010ISO/TS 22789:2010(E) ISO 2010 All rights reserved 32.3 category formal category concept (2.9) represented by a fo
45、rmal definition (2.12) NOTE Adapted from ISO 17115:2007, definition 2.5.3. 2.4 characterizing category formal category (2.3) whose specialization by a domain constraint (2.11) is allowed to be used as characterizing concept (2.5) in a particular context ISO 17115:2007, definition 2.3.3 EXAMPLE =bact
46、erium, virus, parasite, in the context of “Infection that hasCause INFECTIOUS_ORGANISM”. 2.5 characterizing concept concept (2.9) that is referenced by a semantic link (2.17) in a composite characteristic (2.7) ISO 17115:2007, definition 2.2.2 EXAMPLE “Bacterium” in the construct “Disease that hasCa
47、use Bacterium” and “Yellow” in the construct “SkinLesion that hasColor Yellow”. 2.6 characteristic abstraction of a property of an object or of a set of objects ISO 1087-1:2000, definition 3.2.4 NOTE Characteristics are used for describing concepts (2.9). 2.7 composite characteristic qualifier forma
48、l representation of a characteristic (2.6) EXAMPLE hasCause Bacteria; Location = LeftUpperLobeOfLung. NOTE 1 Adapted from ISO 17115:2007, definition 2.2.1. NOTE 2 Can be compared to an attribute-value pair. 2.8 compositional concept representation intensional definition of a concept (2.9) using as d
49、elimiting characteristics one or more composite characteristics (2.7) ISO 17115:2007, definition 2.4.1 NOTE Allows inference and subsumption within a compositional system. Usually expressed in a formalism, such as description logic. 2.9 concept unit of knowledge created by a unique combination of characteristics ISO 1087-1:2000, definition 3.2.1 DD ISO/TS 22789:2010ISO/TS 22789:2010(E) 4 ISO 2010 All rights reserved2.10 concept system system of concepts set of concepts (2.9) struc
