ASTM E1284-97
(Guide)Standard Guide for Construction of a Clinical Nomenclature for Support of Electronic Health Records (Withdrawn 2007)
Standard Guide for Construction of a Clinical Nomenclature for Support of Electronic Health Records (Withdrawn 2007)
SCOPE
1.1 This guide covers the clinical terms used in everyday clinical communications.
1.2 This guide does not cover terminology listings prepared for other purposes such as those for reimbursement, literature retrieval or scientific reference encoding, because the criteria for these types of term lisitngs are significantly different from those to be observed when a nomenclature is constructed for the support of clinical informatics activities.
1.3 This guide is intended to outline the nosologic concepts for a clinical nomenclature that is designed to support electronic healthcare records.
1.4 The purpose of this guide is to describe the desiderata (needed requirement) for a nomenclature that is dedicated to clinical use and can serve as a way for maintaining nationwide compatibility among electronic healthcare records generated in the United States.
1.5 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.
WITHDRAWN RATIONALE
This guide covers the clinical terms used in everyday clinical communication.
Formerly under the jurisdiction of Committee E31 on Healthcare Informatics, this guide was withdrawn in 2007 in accordance with section 10.5.3.1 of the Regulations Governing ASTM Technical Committees, which requires that standards shall be updated by the end of the eighth year since the last approval date.
General Information
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NOTICE: This standard has either been superseded and replaced by a new version or withdrawn.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 1284 – 97
Standard Guide for
Construction of a Clinical Nomenclature for Support of
Electronic Health Records
This standard is issued under the fixed designation E 1284; 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.
INTRODUCTION
The first ASTM guide for the construction of a new clinical nomenclature was published in 1989
(Guide E 1284). It reflected the knowledge and insight of that time. Subsequently, substantial progress
has taken place in this subject area, mostly as part of the efforts toward the development of electronic
healthcare records. These efforts have indicated that a clinical nomenclature is a sine qua non (tool),
the heart of the electronic patient records generation, and the experience gained has provided some
new and some modified criteria for such a clinical nomenclature. These recent developments have
prompted Subcommittee E31.12 to revise Guide E 1284 and to include the new knowledge and
information that has accumulated during the last few years.
1. Scope E 1384 Guide for Description for Content and Structure of
an Automated Primary Record of Care
1.1 This guide covers the clinical terms used in everyday
E 1769 Guide for Properties of Electronic Health Records
clinical communication.
and Record Systems
1.2 This guide does not cover terminology listings prepared
2.2 ISO Standards:
for other purposes such as those for reimbursement, literature
ISO 5218 Information Interchange
retrieval or scientific reference encoding, because the criteria
ISO 2955 Information Processing
for these types of term listings are significantly different from
ISO 8072 Network Standards
those to be observed when a nomenclature is constructed for
ISO 8601 Data Elements and Interchange Formats
the support of clinical informatics activities.
ISO 8859 Information Processing
1.3 This guide is intended to outline the nosologic concepts
ISO 5218 IS Representation of the Human Sexes
for a clinical nomenclature that is designed to support elec-
ISO IS 704 Principles and Methods of Terminology
tronic healthcare records.
ISO DIS 860 International Harmonization of Concepts and
1.4 The purpose of this guide is to describe the desiderata
Terms
(needed requirement) for a nomenclature that is dedicated to
ISO DIS 1087–1 Terminology Work-Vocabulary-Part I:
clinical use and can serve as a way for maintaining nationwide
Theory and Application
compatibility among electronic healthcare records generated in
ISO DIS 1087–2 Terminology Work-Vocabulary-Part II:
the United States.
Computational Aids in Terminology
1.5 This standard does not purport to address all of the
ISO DIS 1951 Lexigraphic Symbols and Typographical
safety concerns, if any, associated with its use. It is the
Conventions for Use in Terminography
responsibility of the user of this standard to establish appro-
ISO TR 9789 Information System Technology—Guidelines
priate safety and health practices and determine the applica-
for the Organization and Representation of Data Elements
bility of regulatory limitations prior to use.
for Data Interchange—Coding Methods and Principles
2. Referenced Documents ISO IS 1024 International Terminology Standards—
Preparation and Layout
2.1 ASTM Standards:
ISO DIS 12616 Translation-Oriented Terminology
ISO DIS 12200 Terminology—Computer Applications—
This guide is under the jurisdiction of ASTM Committee E-31 on Healthcare
Informatics and is the direct responsibility of Subcommittee E31.01 on Controlled
Health Vocabularies for Healthcare Informatics.
Annual Book of ASTM Standards, Vol 14.01.
Current edition approved Aug. 10, 1997. Published March 1998. Originally
Available from American National Standards Institute, 11 W. 42nd St., 13th
published as E 1284–89. Last previous edition E 1284–89.
Floor, New York, NY 10036.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.
E1284–97
Machine Readable Terminology Interchange Format level. The “best” attribute chosen by the architects of the
ISO DIS 12620 Terminology—Computer Applications— nomenclature should be critically evaluated in terms of the
Data Categories current view of clinical practice with regard to that particular
2.3 ANSI Standards: class term partitioning (textbooks, monographs, etc.), and the
ANSI ASCX12 Version 3, Release 3 impact of a particular class term partitioning upon the retrieval
ANSI X3.30 Representation for Calendar Date and Ordi- of that term or related terms in actual usage.
nary Date
3.1.6 concept—a summarizing abstract idea derived from a
ANSI X3.43 Information Systems Representation of Local generalizing process, following an abstracting mental process.
Time of Day for Information Exchange
Concept is a general notion to represent a class of objects.
ANSI X3.51 Representations of Universal Time, Local
3.1.6.1 clinical concept—a mental image generated and
Time Differentials, and United States Time Zone Refer-
used within the domain of clinical activities, based on the
ences for Information Interchange
characteristics of a class of real-world instances, including the
2.4 Other Standards:
features typically associated with or suggested by that image.
HL7: Health Level Seven Version 2.2
3.1.7 health record—the collection of data and information
ACR/NEMA: DICOM Version 3.0
gathered, or generated, to document (clinical care rendered to
CEN ENV 12262 Model of Semantics
an individual) the conditions of an individual and any health
care planned, ordered, or rendered.
3. Terminology
3.1.7.1 electronic health record—a comprehensive, struc-
3.1 Definitions of Terms Specific to This Standard: Term
tured set of clinical, demographic environmental, social, and
definitions in this section are limited to the characterization of
financialdataandinformation,inelectronicform,documenting
the meaning of terms in context of this guide, namely, the
the health care planned, ordered, or rendered related to a single
meaning for construction of a clinical nomenclature for the
individual. The electronic health record may include health
support of automated creation of electronic health records.
related information from non-clinical sources that may not
3.1.1 attribute selection for hierarchical classification—
fully conform to the standardized clinical nomenclature. Even
choice of a characterizing feature of a class of concepts that
so, when possible, such information should be interpreted and
allows partitioning, as defined by the architects of the classi-
classified, according to the paradigm of the clinical nomencla-
fication system. (Three most successful classification systems
ture. This will allow handling such material effectively.
used a single attribute: botany used binomial attribute, biology
3.1.8 hierarchical classified system—a special subset of
relatedclassificationtoevolution,chemistryutilizedtheatomic
classified systems with stepwise ranking of the concepts where
weight.)
subordinated lower level concepts are the result of a partition-
3.1.2 class term—a term that encompasses terms that are in
ing process, based on a preselected and clearly stated at-
one sense similar but in some another sense heterogeneous,
tribute(s).
dissimilar. A class term is clinically meaningfully partitioned,
3.1.9 lexical meaning—the definition of the meaning, a
when this partitioning results in subclasses with increased
word or phrase generally, out of context, as listed in appropri-
similarity among the members of each subclass.
ate lexicons, such as medical dictionaries.
3.1.3 class term partitioning—the act of separating a class
3.1.10 nomenclature—comprehensive systematized termi-
concepts into subclasses, where the created subclasses include
nology where the preferred terms are ordered into a classified
all members of the partitioned class term.
system based on their meaning and where semantic kinships
3.1.4 classified system—systematic arrangement of con-
are held together.
cepts into categories according to preset explicit criteria,
3.1.11 nosology—thescienceandtechnologyofnamingand
following a chosen nosologic scheme, such a hierarchical or
classifying clinical concepts, such as anatomic terms, bio-
matrix arrangement.
chemical and physiologic terms, symptoms, signs, clinical
3.1.5 compound hierarchy—a stepwise hierarchical ar-
problems and diagnoses, terms of etiology and therapy, nurs-
rangement where more than one attribute is used for partition-
ing, and others used by healthcare team members. Nosology is
ing. The most appropriate attribute to guide the act of parti-
domain specific.
tioning is chosen by the architects of the nomenclature.
3.1.11.1 nosologic sheme—a currently accepted and pre-
3.1.5.1 Discussion—Design of a particular equally good
vailing thinking about organization of clinical concepts based
hierarchy tree is not to be viewed as necessarily the only
on accepted classification theories (probabilistic reasoning,
acceptable partitioning scheme. An alternative is the matrix
fuzzy set theory, etc.).
design. Furthermore, partitioning of some class terms is
3.1.12 single-key hierarchy—also called directly hierarchy,
controversial. For example, the concept anemia, an obvious
is a stepwise hierarchical arrangement of concepts using the
classterm,maybepartitionedonthebasisofthesizeofthered
same single attribute (the key) for partitioning throughout the
cells (nomocytic, macrocytic and microcytic anemias), by the
nomenclature.
use of erythrokinetic differences (increased loss or insufficient
3.1.12.1 Discussion—Theoretically, all clinical terms
production of red cells), or on the basis of the reticulocyte
should be classifiable into a single-key hierarchy where all
class terms and subclass terms are based on a single key such
as etiology, or outcome, or some other preselected key at-
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