ASTM E2457-06
(Terminology)Standard Terminology for Healthcare Informatics
Standard Terminology for Healthcare Informatics
SCOPE
1.1 This terminology is intended to name and document the principal concepts, and their associated terms, that are utilized in the healthcare information domain and all of its specialized subdomains. It is applicable to all areas of healthcare about which information is kept or utilized. It is intended to complement and utilize those concepts already identified by other national and international standards bodies. It will identify alternate accepted terms for the same concept and its elected term. Its terms are intended to clarify and simplify usage in the dialog and documentation about the concepts, processes and data that are used to schedule, conduct and manage all phases of healthcare. This common usage will improve the quality and management of all facets of healthcare by means of explicit information used in referring to each of these facets. These health informatics terms have been collected here specifically in order to facilitate the consistent use of common concepts in informatics standards development and use throughout healthcare. A separate process from this standard that is described in ISO 15188 will manage the approval of biomedical and healthcare terms.
1.2 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use.
General Information
Relations
Standards Content (Sample)
NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.
Contact ASTM International (www.astm.org) for the latest information
An American National Standard
Designation: E 2457 – 06
Standard Terminology for
Healthcare Informatics
This standard is issued under the fixed designation E 2457; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (e) indicates an editorial change since the last revision or reapproval.
1. Scope Health Record (EHR)
E 1633 Specification for Coded Values Used in the Elec-
1.1 This terminology is intended to name and document the
tronic Health Record
principal concepts, and their associated terms, that are utilized
E 1869 Guide for Confidentiality, Privacy,Access, and Data
in the healthcare information domain and all of its specialized
Security Principles for Health Information Including Elec-
subdomains. It is applicable to all areas of healthcare about
tronic Health Records
which information is kept or utilized. It is intended to comple-
E 1985 Guide for User Authentication and Authorization
ment and utilize those concepts already identified by other
E 1986 Guide for Information Access Privileges to Health
national and international standards bodies. It will identify
Information
alternate accepted terms for the same concept and its elected
E 1987 Guide for Individual Rights Regarding Health In-
term. Its terms are intended to clarify and simplify usage in the
formation
dialog and documentation about the concepts, processes and
E 2087 Specification for Quality Indicators for Controlled
data that are used to schedule, conduct and manage all phases
Health Vocabularies
ofhealthcare.Thiscommonusagewillimprovethequalityand
E 2147 Specification forAudit and Disclosure Logs for Use
management of all facets of healthcare by means of explicit
in Health Information Systems
information used in referring to each of these facets. These
2.2 CEN Standards:
health informatics terms have been collected here specifically
EN-12017 Medical Informatics Vocabulary (MIVoc)
in order to facilitate the consistent use of common concepts in
EN-12264 Categorical Structure of Syntax of Concepts—
informatics standards development and use throughout health-
Model for Representation of Semantics (MOSE)
care.Aseparate process from this standard that is described in
2.3 ISO Standards:
ISO 15188 will manage the approval of biomedical and health-
ISO 704 Principles and Methods of Terminology
care terms.
ISO/DIS 860 International Harmonization of Concepts and
1.2 This standard does not purport to address all of the
Terms
safety concerns, if any, associated with its use. It is the
ISO/DIS 1087-1 Terminology—Vocabulary—Part 1Theory
responsibility of the user of this standard to establish appro-
and Application
priate safety and health practices and determine the applica-
ISO/DIS 1087-2 Terminology—Vocabulary—Part 2 Com-
bility of regulatory limitations prior to use.
puter Applications
2. Referenced Documents
ISO 2382/4 Information Technology—Vocabulary—
Organization of Data
2.1 ASTM Standards:
ISO 10241 Terminology—Standards Representation and
E 1239 Practice for Description of Reservation/
Layout
Registration-Admission, Discharge, Transfer (R-ADT)
ISO 12200 Terminology—Computer Applications—
Systems for Electronic Health Record (EHR) Systems
Machine Readable Terminology Interchange Format
E 1284 Guide for Construction of a Clinical Nomenclature
ISO/IEC 12207 Life Cycle Processes
for Support of Electronic Health Records
ISO 12620 Terminology—Computer Applications—Data
E 1384 Practice for Content and Structure of the Electronic
Categories
ISO 15188 Project Management Guidelines for Terminol-
ogy Interchange Format
This terminology is under the jurisdiction of ASTM Committee E31 on
2.4 Other Documents:
Healthcare Informatics and is the direct responsibility of Subcommittee E31.35 on
Healthcare Data Analysis.
Current edition approved July 17, 2006. Published March 2006.
For referenced ASTM standards, visit the ASTM website, www.astm.org, or
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM Available from European Committee for Standardization (CEN), 36 rue de
Standards volume information, refer to the standard’s Document Summary page on Stassart, B-1050, Brussels, Belgium.
the ASTM website. Available fromAmerican National Standards Institute (ANSI), 25 W. 43rd St.,
Withdrawn. 4th Floor, New York, NY 10036.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
E2457–06
American National Standard Dictionary of Information technical dictionary—dictionary of terminologic entries or
Technology (ANSDIT) http:/www.incits.org designation-related information, from one or more specific
CEN PrENV 11994 Medical Informatics Vocabulary subject fields.
GALEN Generalized Architecture for Language, Encyclo- term—designation consisting of one or more words which
pedias and Nomenclatures in Medicine: Univ. of denote a given concept in a special language (language for
Manchester special purposes).
IEEE 610.5 Glossary of Data Management terminology—set of terms belonging to one special language.
Unified Medical Language System (UMLS) Knowledge vocabulary—technical dictionary that contains designations
Sources National Library of Medicine 7th Experimental and definitions from one or more special subject fields.
Edition January 1996 4.3 Definitions of Terms Specific to This Standard:
candidate term—that form which has been submitted to the
3. Significance and Use reference body for election as that to be used in data
interchange and in situations requiring wide understanding
3.1 This standard vocabulary is intended to be used as a
but which has not yet achieved that election.
reference about terms used in standards for healthcare infor-
data element—(1) named unit of data that, in some contexts,
matics and in general discussions about informatics issues
isconsideredindivisibleandinothercontextsmayconsistof
relating to the healthcare sector, including: clinical care,
data items; and (2) a named identifier of each of the entities
resource management, policy, clinical or health services re-
and their attributes that are represented in a database.
search or biomedical research in basic or applied areas of
ANSI X3.172-1990
science that refer to the healthcare sector. It contains “Elected
data item—named component of a data element; usually the
Terms” rather than the “Preferred” terms used in the termino-
smallest component. ANSI X3.172-1990
logic literature. This is a usage coined within the CEN TC-251
data value—instance of a data item. ANSI X3.172-1990
community to reflect the fact that there is consensus agreement
elected term—that form which is rapidly and fully understood
on the usage of a particular form rather than an imposition.
as representing the defined concept and which has been
This consensual agreement to usage better reflects the incen-
agreed by consensus that it will stand for that concept in the
tives for common usage rather than mandates.Alternate forms
wide majority of situations where that concept is noted.
(Synonymy) of an elected term exist and are cataloged for the
lexicon—collection of terms used in a particular profession or
same concept, in accordance with ISO/DIS 1087-1, ISO 704,
subject area.
ISO 12620, and EN-12017, ISO/DIS 860, EN-12264, and
4.4 Acronyms:
ANSDIT.
ANSI HITSP—American National Standards Institute Health
3.2 The system used to classify these terms is in the full
Information Technology Standards Panel
context of all of the terminology of biomedicine, as well as
CEN—Committee European Normalization
about the healthcare system itself as it is used throughout the
HL7—Health Level Seven
health domain. It has drawn on the terms used in both
ISO—International Standards Organization
EN-12017 and in UMLS for biomedicine (Guide E 1284,
SDO—Standards Developer Organization
Specification E 1633, ISO 12200, GALEN). The coding
scheme described in Section 5 used to represent this classifi-
5. Classification Schema
cation was developed for this terminology from the Unified
Medical Language System documentation produced by the
5.1 The rationale for placement of healthcare informatics
National Library of Medicine.
terms within an existing schema involves combination of
concepts given in EN-12017 with that of the Semantic Types
4. Terminology
used in UMLS (v-7, p. 30) by adding groups and subgroups
from EN-12017 to new sub categories in UMLS.The locations
4.1 Vocabulary about Vocabulary—This section lists those
of these insertions are shown as follows:
terms used for vocabulary in this document which do not
EN 12017 classification shown in ( )
appear in the above referenced standards; however, the follow-
Extensions to UMLS Semantic Type in Bold
ing general terms in ISO/DIS 1087-1 are included for under-
standing:
A. Entity
2. Conceptual entity
4.2 ISO/DIS 1087-1 Terms:
1. Idea or Concept
2. Finding
admitted term—term accepted as a synonym for a preferred
3. Organism Attribute
term by an authoritative body.
4. Intellectual Product
designation—representation of a concept by linguistic or
5. Language
6. Occupation or Discipline
non-linguistic means.
1. Biomedicine Occupation or Discipline
2. Professional, Service, Administrative, Agricultural or Manufacturing
DISCUSSION—In terminologic work, Symbols and Terms are the two
Occupation
designations.
7. Organization (1.2.3)
1. Healthcare related organization
glossary—documentthatcontainsalistoftermsfromasubject
1. Healthcare-delivery organization (1.2.3.1)
field and their designations.
2. Issuing organization (1.2.3.2)
preferredterm—termrecommendedbyanauthoritativebody. 3. Registration authority (1.2.3.3)
4. Sponsoring authority (1.2.3.4)
special language—language for special purposes.
E2457–06
5. Healthcare Facility 4. Devices (2.4)
2. Professional Society 1. Intermittently Connected Device (2.4.1)
3. Self-help or relief organization 2. Healthcare Person Device (2.4.2)
4. Healthcare party (1.2.4) 3. Electronic Healthcare Cards (2.4.3)
1. Laboratory service provider (1.2.4.1) 5. Data (2.5)
2. Laboratory service requester (1.2.4.2) 1. Data types (2.5.1)
3. Subject of Investigation (1.2.4.3) 2. Data structures (2.5.2)
4. Consent (1.2.4.4) 3. Codes (2.5.3)
5. Healthcare accountability (1.2.5) 4. Record (2.5.4)
1. Contract 1. Healthcare record (2.5.4.1)
2. Management 5. Register (2.5.5)
3. Professional License 6. Healthcare statistics (2.5.6)
6. Healthcare Enterprise (1.2.7.1) 7. ECG Data (2.5.7)
1. Healthcare enterprise constituencies (1.2.7.1.1) B. Event
2. Healthcare enterprise dimensions (1.2.7.1.2) 1. Activity
3. Healthcare enterprise view (1.2.7.1.3) 3. Occupational Activity
7. Organizational policies (1.2.7.2) 1. Healthcare Activity (1.1)
8. Organizational strategies (1.2.7.3) 1. Healthcare Service (1.1.1)
8. Group attribute 1. Diagnostic Procedure (1.1.1.1)
9. Group 1. Investigation (1.1.1.1.1)
1. Professional or Occupational Group 1. Laboratory Examination (1.1.1.1.1.1)
1. Healthcare Players (1.2) 2. Therapeutic/Preventive Procedure
1. Healthcare professionals (1.2.2) 1. Surgical Deed (1.1.1.2)
1. Healthcare practitioner (1.2.2.1) 2. Nursing Procedure (1.1.1.3)
2. Healthcare workers 3. Administrative service
2. Population 4. Clinical Service
3. Family 2. Ancillary Service (1.1.1.2)
4. Age 3. Telemedicine (1.1.1.3)
5. Patient or Disabled Group 4. Healthcare Scheduling/appointing (1.1.2)
1. Individual Patient 5. Clinical Orders (1.1.3)
10. Resources (1.3) 1. Laboratory service order (1.1.3.1)
1. Healthcare Informatics (1.3.1) 6. Quality assurance (1.1.4)
1. Health Information Technology (1.3.1.1) 2. Research Activity
1. Health Information Technology Components (1.3.1.1.1) 3. Governmental or Regulatory Activity
2. Healthcare Technology (1.3.2) 4. Educational Activity
1. Health technology components (1.3.2.1) 2. Phenomenon or Process
2. Interventional equipment (1.3.2.2) 1. Anthropogenic phenomenon
3. ECG Devices (1.3.2.3) 2. Natural phenomenon
4. Safety (1.3.2.4) 1. Biologic Function
3. Healthcare System/Setting 1. Physiologic Function
11. Informatics (2.) 2. Pathologic Function
1. Informatics Basics (2.1)
1. Terminology (2.1.1)
6. Terms and Definitions: Current Elected Terms
1. Concept (2.1.1.1)
1. Concept Type (2.1.1.1.1)
6.1 Annex A1 contains the entries currently elected by the
2. Concept System (2.1.1.1.2)
3. Composite Concept (2.1.1.1.3) subcommittees of ASTM Technical Committee E31 and sub-
4. Type of Modifier (2.1.1.1.4)
mitted to other SDOs of the ANSI HITSP. Terms not fully
2. Characteristic (2.1.1.2)
agreed upon by these bodies are also listed in the next section
3. Term (2.1.1.3)
4. Object (2.1.1.4)
on candidate terms. This Elected term list is prepared accord-
2. Modelling (2.1.2)
ing to ISO 10241. A number of terms come from the CEN
1. Information Domain (2.1.2.1)
2. Functional Domain (2.1.2.2) Standard EN-12017 MIVOC.
3. View (2.1.2.3)
4. Modeling Technique (2.1.2.4)
7. Terms and Definitions: Candidate Terms
2. Information Systems (2.2)
1. Information System (2.2.1)
7.1 AnnexA2 includes that list of candidate terms (without
2. Information (2.2.2)
3. Data Security (2.2.3)
definitions) for which full consensus has not yet been reached
1. Confidentiality (2.2.3.1)
but which are widely used either in the elected or alternate
2. Privacy (2.2.3.2)
forms. Continuing work is underway to elect the form which is
3. Cryptography (2.2.3.3)
4. Access Control (2.2.3.4)
intended to be that widely recognized for the defined concept.
5. Data Availability (2.2.3.5)
Upon election, the term entry (with elected definition) will be
6. Data Integrity (2.2.3.6)
7. Security Audit (2.2.3.7)
transferred toAnnexA1. Candidate terms are further classified
8. Security Policy (2.2.3.8)
in Appendix X1 by the taxonomy given in 4.1.
9. Threat (2.2.3.9)
10. Physical Security (2.2.3.10)
3. Processes (2.3)
8. Keywords
1. Data access (2.3.1)
2. Imaging (2.3.2)
8.1 healthcare information domain; health informatics; ter-
3. Communication (2.3.3)
minology; vocabulary
4. Measurement (2.3.4)
E2457–06
ANNEXES
(Mandatory Information)
A1. ELECTED TERMS
NOTE A1.1—No terms yet Elected.
15. CPRI
16. Guide E 1985
A1.1 Term Sources 17. Specification E 2147
18. Guide E 1986
1. CEN PrENV 11994
19. Guide E 1987
2. EN-12017
20. ISO/IEC 12207
3. CEN Global Glossary
21. IEEE 610.5
4. AHIMA Glossary
22. Zachman 1987
5. Andover Working Group Glossary
23. Glaser 2002
6. DoD Glossary
24. Terminology E 2457
7. Practice E 1384
25. TC-215 WG3
8 Practice E 1239
26. ISO/DIS 1087-1
9. Guide E 1869
27. ISO/DIS 1087-1 CANDIDATE
10. Institute of Medicine 1991 rev 1997
28. Specificatio
...
Questions, Comments and Discussion
Ask us and Technical Secretary will try to provide an answer. You can facilitate discussion about the standard in here.