ASTM E1715-01(2008)
(Practice)Standard Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
Standard Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems
SIGNIFICANCE AND USE
RADT Object Model as a Basis for Communication—The RADT object model is the first model used to create a common library of consistent entities (objects) and their attributes in the terminology of object analytical models as applied to the healthcare domain. These object models can be used to construct and refine standards relating to healt care information and its management. Since the RADT object model underpins the design and implementation of specific systems, it provides the framework for establishing the systematics of managing observations made during health care. The observations recorded during health care not only become the basis for managing an individual's health care by practitioners but are also used for research and resource management. They define the common language for abstracting and codifying observations. The inconsistency and incompleteness of the data recorded in paper records is well known and has been noted by the Institute of Medicine's study (4). The ability to build the recommended EHR begins with RADT, as noted in Practice E 1239. A more detailed specification of the RADT process and its specific functional domain shall begin with a formal model. Furthermore, following agreement on the initial model, that model shall evolve as knowledge accumulates and the initial view of the healthcare domain extends to other social and psychologic processes that link healthcare with other functional domains of society. The management of lifelong cases of care, such as those of birth defects in newborns, will involve interactions with social work and educational functional domains of experience. It has been recognized for some time (5) that a “healthcare team,” in the broader sense, is involved in dealing with these complex cases. The RADT model is the core to linking these functional domains together in a transparent way. For that reason, the object terminology is used to enable the most global view and vernacular that will facilitate communication amo...
SCOPE
1.1 This practice is intended to amplify Practice E 1239 and to complement Practice E 1384 by detailing the objects that make up the reservation, registration, admitting, discharge, and transfer (RADT) functional domain of the computer-based record of care (CPR). As identified in Practice E 1239, this domain is seminal to all patient record and ancillary system functions, including messaging functions used in telecommunications. For example, it is applicable to clinical laboratory information management systems, pharmacy information management systems, and radiology, or other image management, information management systems. The object model terminology is used to be compatible with other national and international standards for healthcare data and information systems engineering or telecommunications standards applied to healthcare data or systems. This practice is intended for those familiar with modeling concepts, system design, and implementation. It is not intended for the general computer user or as an initial introduction to the concepts.
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Designation: E1715 − 01(Reapproved 2008) An American National Standard
Standard Practice for
An Object-Oriented Model for Registration, Admitting,
Discharge, and Transfer (RADT) Functions in Computer-
1
Based Patient Record Systems
This standard is issued under the fixed designation E1715; 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 (´) indicates an editorial change since the last revision or reapproval.
1. Scope E1633 SpecificationforCodedValuesUsedintheElectronic
Health Record
1.1 This practice is intended to amplify Practice E1239 and
E1639 Guide for Functional Requirements of Clinical Labo-
to complement Practice E1384 by detailing the objects that
ratory Information Management Systems (Withdrawn
make up the reservation, registration, admitting, discharge, and
3
2002)
transfer (RADT) functional domain of the computer-based
E1744 Practice for View of Emergency Medical Care in the
record of care (CPR). As identified in Practice E1239, this
Electronic Health Record
domain is seminal to all patient record and ancillary system
F1629 Guide for Establishing Operating Emergency Medi-
functions, including messaging functions used in telecommu-
cal Services and Management Information Systems, or
nications. For example, it is applicable to clinical laboratory
Both
information management systems, pharmacy information man-
2.2 ANSI Standard:
agement systems, and radiology, or other image management,
4
ANSI X3.172 Dictionary of Information Systems
information management systems. The object model terminol-
2.3 IEEE Standard:
ogy is used to be compatible with other national and interna-
IEEE 1157.1 Trial Use Standard for Healthcare Information
tional standards for healthcare data and information systems
5
Interchange—Information Modelling (6 June 1994)
engineeringortelecommunicationsstandardsappliedtohealth-
2.4 Other Document:
care data or systems. This practice is intended for those
6
HL-7 v2.4 Data Communication Standard
familiar with modeling concepts, system design, and imple-
mentation.Itisnotintendedforthegeneralcomputeruseroras
3. Terminology
an initial introduction to the concepts.
3.1 Definitions—General terms are defined in accordance
2. Referenced Documents
with ANSI X3.172.
2
2.1 ASTM Standards:
3.2 Definitions of Terms Specific to This Standard:
E1238 Specification for Transferring Clinical Observations
3.2.1 functional domain, n—thatareaofactivitythatencom-
Between Independent Computer Systems (Withdrawn
passes a given function. (HL-7, v2.4)
3
2002)
3.2.2 healthcare domain, n—that functional domain encom-
E1239 Practice for Description of Reservation/Registration-
passing all aspects of the delivery of health care, both preven-
Admission, Discharge, Transfer (R-ADT) Systems for
tive and corrective, to patients, and the management of
Electronic Health Record (EHR) Systems
resources enabling that care to be delivered. (HL-7, v2.4)
E1384 Practice for Content and Structure of the Electronic
Health Record (EHR)
4. Background
4.1 Object Representation of RADT Processes—Practice
1
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare
E1239 provides the experiential background of the functions in
Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare
RADT. These functions are common to all systems that deal
Data Management, Security, Confidentiality, and Privacy.
with patient data. The minimal essential data elements for
Current edition approved Sept. 15, 2008. Published December 2008. Originally
approved in 1995. Last previous edition approved in 2001 as E1715 – 01. DOI:
10.1520/E1715-01R08.
2 4
For referenced ASTM standards, visit the ASTM website, www.astm.org, or Available fromAmerican National Standards Institute (ANSI), 25 W. 43rd St.,
contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM 4th Floor, New York, NY 10036, http://www.ansi.org.
5
Standards volume information, refer to the standard’s Document Summary page on Available from Institute of Electrical and Electronics Engineers, Inc. (IEEE),
the ASTM website. 445 Hoes Ln., P.O. Box 1331, Piscataway, NJ 08854-1331, http://www.ieee.org.
3 6
The last approved version of this historical standard is referenced on AvailablefromHealthLevelSeven,900VictorsWay,Suite122,AnnArbor,MI
www.astm.org. 48108.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
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E1715 − 01 (2008)
RADT were identified and characterized partly in Practice yet been agreed on formally. The objects included here are
E1239. Table 1 of that guide identifies a logical data
...
This document is not anASTM standard and is intended only to provide the user of anASTM standard an indication of what changes have been made to the previous version. Because
it may not be technically possible to adequately depict all changes accurately, ASTM recommends that users consult prior editions as appropriate. In all cases only the current version
of the standard as published by ASTM is to be considered the official document.
An American National Standard
Designation:E1715–99 Designation: E 1715 – 01 (Reapproved 2008)
Standard Practice for
An Object-Oriented Model for Registration, Admitting,
Discharge, and Transfer (RADT) Functions in Computer-
1
Based Patient Record Systems
This standard is issued under the fixed designation E 1715; 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 (´) indicates an editorial change since the last revision or reapproval.
1. Scope
1.1 ThispracticeisintendedtoamplifyGuidePracticeE 1239andtocomplementGuidePracticeE 1384bydetailingtheobjects
that make up the reservation, registration, admitting, discharge, and transfer (RADT) functional domain of the computer-based
record of care (CPR). As identified in GuidePractice E 1239, this domain is seminal to all patient record and ancillary system
functions, including messaging functions used in telecommunications. For example, it is applicable to clinical laboratory
information management systems, pharmacy information management systems, and radiology, or other image management,
information management systems. The object model terminology is used to be compatible with other national and international
standards for healthcare data and information systems engineering or telecommunications standards applied to healthcare data or
systems.This practice is intended for those familiar with modeling concepts, system design, and implementation. It is not intended
for the general computer user or as an initial introduction to the concepts.
2. Referenced Documents
2
2.1 ASTM Standards:
E 1238 Specification for Transferring Clinical Observations Between Independent Computer Systems
E 1239Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (RADT) Systems for Automated
2
Patient Care Information Systems Practice for Description of Reservation/Registration-Admission, Discharge, Transfer
(R-ADT) Systems for Electronic Health Record (EHR) Systems
2
E 1384Guide for Description for Content and Structure of an Automated Primary Record of Care
2
E1633Specification for Coded Values Used in Computer-Based Patient Record Practice for Content and Structure of the
Electronic Health Record (EHR)
E 1633 Specification for Coded Values Used in the Electronic Health Record
E 1639 Guide for Functional Requirements of Clinical Laboratory Information Management Systems
E 1744Guide Practice for a View of Emergency Medical Care in the Computer-Based PatientElectronic Health Record
F 1629 Guide for Establishing and/or Operating Emergency Medical Services and Management Information Systems, or Both
2.2 ANSI Standard:
3
ANSI X3.172 Dictionary of Information Systems
2.3 IEEE Standard:
4
IEEE 1157.1 Trial Use Standard for Healthcare Information Interchange—Information Modelling (6 June 1994)
2.4 Other Document:
5
HL-7v2.2 v2.4 Data Communication Standard
1
This practice is under the jurisdiction ofASTM Committee E-31 on Healthcare Informatics and is the direct responsibility of Subcommittee E31.19 on Computer–Based
Patient Record Content and Structure.
Current edition approved Jan. 10, 1999. Published March 1999. Originally published as E 1744–95. Last previous edition E 1744–95.
1
This practice is under the jurisdiction ofASTM Committee E31 on Healthcare Informatics and is the direct responsibility of Subcommittee E31.25 on Healthcare Data
Management, Security, Confidentiality, and Privacy.
Current edition approved Sept. 15, 2008. Published December 2008. Originally approved in 1995. Last previous edition approved in 2001 as E 1715 – 01.
2
For referencedASTM standards, visit theASTM website, www.astm.org, or contactASTM Customer Service at service@astm.org. For Annual Book of ASTM Standards
, Vol 14.01.volume information, refer to the standard’s Document Summary page on the ASTM website.
3
Available from American National Standards Institute, 11 W. 42nd St., 13th Floor, New York, NY 10036.
3
Available from American National Standards Institute (ANSI), 25 W. 43rd St., 4th Floor, New York, NY 10036, http://www.ansi.org.
4
Available from IEEE, 445 Hoes Lane, P.O. Box 1331, Piscataway, NJ 08855-1331.
4
Available from Institute of Electrical and Electronics Engineers, Inc. (IEEE), 445 Hoes Ln., P.O. Box 1331, Piscataway, NJ 08854-1331, http://www.ieee.org.
5
Available from Health Level Seven, 900 Victors Way, Suite 122, Ann Arbor, MI 48108.
Copyright © ASTM Internation
...
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