ISO/TR 6231:2024

Health informatics - Standardizing graphical content

This document describes the need for standardization of graphics and images in the health informatics domain. It focuses on the current status of adoption and presents an overview of the opportunities as well as challenges in creating sets of standardized images and graphics. A plan of action is proposed to serve as the future roadmap for implementation.

Informatique de santé — Normalisation du contenu graphique

General Information

• Status: Published
• Publication Date: 05-Jun-2024
• ICS: 35.240.80 - IT applications in health care technology
• Technical Committee: ISO/TC 215 - Health informatics
• Drafting Committee: ISO/TC 215 - Health informatics
• Current Stage: 6060 - International Standard published
• Start Date: 06-Jun-2024
• Completion Date: 06-Jun-2024

Overview - ISO/TR 6231:2024 (Health informatics - Standardizing graphical content)

ISO/TR 6231:2024 is a Technical Report from ISO/TC 215 that documents the need, status, opportunities and challenges for standardizing graphics and images in health informatics. The report is a first-edition, non‑normative guide that: explains why visual content matters for clinical interoperability and telehealth; surveys current efforts and example uses; and proposes a plan of action and roadmap for implementation of standardized healthcare graphics.

Key technical topics and guidance

The report focuses on practical, implementation‑oriented topics rather than prescriptive requirements. Major technical areas covered include:

• Terminology and semantics - integration of graphics with clinical terminologies (e.g., SNOMED CT), post‑ and pre‑coordination concepts, and mapping strategies.
• Graphics use cases - examples for EHR toolbars, PC and mobile apps, help files, toolboxes, and palettes for consistent UI/UX.
• Interoperability needs - exchanging graphical content across systems, telehealth workflows, and during disaster response or cross‑cultural encounters.
• Technical enablers - implications for NLP, AI, and medical devices that consume or produce graphical annotations.
• Governance and implementation roadmap - proposed actions for creating, curating and adopting standardized image sets.
• Challenges and gaps - accessibility, cultural variability, intellectual property, implementation cost and tooling needs.

Note: as a Technical Report, ISO/TR 6231:2024 presents analysis and recommended actions rather than normative requirements.

Practical applications and users

ISO/TR 6231:2024 is designed to help organizations and professionals who deal with visual content in healthcare IT. Typical beneficiaries:

• Application developers and UI/UX teams building EHRs, telehealth and mobile health apps.
• Telehealth solution providers seeking consistent visual cues across platforms.
• Terminology and ontology managers integrating images with coded clinical concepts.
• Clinicians and care teams who annotate patient records with standardized visuals (e.g., pain, wounds).
• Medical device manufacturers, AI/NLP developers, informaticians, analysts and researchers.

Practical benefits include improved cross‑language communication, consistent patient documentation, better interoperability in telehealth, and more robust training data for AI.

Related standards and references

ISO/TR 6231:2024 complements existing health informatics standards referenced in the report, such as:

• SNOMED CT (clinical terminology)
• ISO/TS 21089 (coding schemes)
• ISO 13606‑1 (EHR architectures)
• ISO/TR 24291, ISO 18308 and related ISO terminology references

For organizations implementing visual standards in health IT, ISO/TR 6231:2024 provides a strategic foundation and roadmap for harmonizing graphical content across systems and contexts.

Standards Content (Sample)

Technical
Report
ISO/TR 6231
First edition
Health informatics — Standardizing
2024-06
graphical content
Informatique de santé — Normalisation du contenu graphique
Reference number
© ISO 2024
All rights reserved. Unless otherwise specified, or required in the context of its implementation, no part of this publication may
be reproduced or utilized otherwise in any form or by any means, electronic or mechanical, including photocopying, or posting on
the internet or an intranet, without prior written permission. Permission can be requested from either ISO at the address below
or ISO’s member body in the country of the requester.
ISO copyright office
CP 401 • Ch. de Blandonnet 8
CH-1214 Vernier, Geneva
Phone: [phone]
Email: [e-mail]
Website: www.iso.org
Published in Switzerland
ii
Contents Page
Foreword .iv
Introduction .v
1 Scope . 1
2 Normative references . 1
3 Terms and definitions . 1
3.1 General terms .1
3.2 Terms related to information management .2
3.3 Terms related to healthcare .3
3.4 Terms related to graphical information.4
4 Overview . 5
5 Current efforts of graphics standardization . 7
6 Example sets of healthcare graphics usage. 8
6.1 General .8
6.2 Working with terminologies .8
6.3 EHR and applications toolbar .9
6.4 Use within PC based and mobile applications .10
6.5 Creating a standard palette or toolbox .14
6.6 Natural language processing (NLP) .14
6.7 Helpfiles and suggestions . 15
6.8 Medical devices . 15
6.9 Artificial intelligence (AI) . 15
7 Challenges regarding graphics standardization .16
Bibliography . 17

iii
Foreword
ISO (the International Organization 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 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.
The procedures used to develop this document and those intended for its further maintenance are described
in the ISO/IEC Directives, Part 1. In particular, the different approval criteria needed for the different types
of ISO document should be noted. This document was drafted in accordance with the editorial rules of the
ISO/IEC Directives, Part 2 (see www.iso.org/directives).
ISO draws attention to the possibility that the implementation of this document may involve the use of (a)
patent(s). ISO takes no position concerning the evidence, validity or applicability of any claimed patent
rights in respect thereof. As of the date of publication of this document, ISO had not received notice of (a)
patent(s) which may be required to implement this document. However, implementers are cautioned that
this may not represent the latest information, which may be obtained from the patent database available at
www.iso.org/patents. ISO shall not be held responsible for identifying any or all such patent rights.
Any trade name used in this document is information given for the convenience of users and does not
constitute an endorsement.
For an explanation of the voluntary nature of standards, the meaning of ISO specific terms and expressions
related to conformity assessment, as well as information about ISO's adherence to the World Trade
Organization (WTO) principles in the Technical Barriers to Trade (TBT), see www.iso.org/iso/foreword.html.
This document was prepared by Technical Committee ISO/TC 215, Health informatics.
Any feedback or questions on this document should be directed to the user’s national standards body. A
complete listing of these bodies can be found at www.iso.org/members.html.

iv
Introduction
Images and graphics predate any formal written human communication. Cave paintings and engravings have
given pointers to lifestyles and methods from ancient times. Pictograms describing health problems have
been found as engravings and drawings in the Egyptian pyramids (approximately 2 500 BC), the frescoes
st
and road signs in Pompei (approximately 1 century AD) and the murals in the ancient temples of India such
as Konark Sun Temple (1 250 AD). They have helped retrace the history of medicine and given an idea of
health problems existing in those times. More importantly, their usage transcended language barriers.
Healthcare needs are universal. The health information technology sector depends on accurate and
consistent transfer of information relevant to the health care providers and their patients. The focus is on
finding convenient and universally understood methods for information transfer. In this context, graphics
usage in the form of emojis, emoticons and stickers has become an indispensable tool in enhancing online
communications and making it richer and more emotive. Healthcare applications are also adopting graphics,
but their usage is still less prevalent than in other fields. One of the major reasons behind this is the lack of
standardization in this field. This document attempts to stimulate interest, emphasize the need, and suggest
ways for better usage of graphics in healthcare information technology.
With rising life expectancy, along with higher incidence of non-communicable diseases (NCDs), there is a
constant need for care support. Advances in telecommunication have allowed this to be offered remotely
through telehealth systems. Even before the COVID period, 76 % of US citizens preferred remote care over a
[19]
physical visit .
Telehealth has spurred the need for interoperability standards. Telehealth usage increased exponentially
globally following the COVID pandemic. With global warming and related environmental issues, the
frequency of other natural disasters has increased. During disasters, the need for remote support increases
the interchange of health-related communication, even among communities and people who have never met
before. Improved travel facilities have given rise to tourism, and especially medical tourism. Migration is also
a rising phenomenon. Both medical tourism and migration increase the possibility of language and cultural
differences between the care provider and the patient. Thus, methods to easily transfer health information
across platforms and language barriers can help achieve consistent and uniform delivery of care.
Graphics and visually relatable content, for example locating injuries or pain with additional on-the-spot
markings, have been long used for medical record keeping. However, these are not yet standardized.
This document extrapolates the need and current status of health-related graphics standardization.
Likely beneficiaries of this document include:
— application developers;
— telehealth solution providers;
— those working in the social media workspace;
— those working with terminologies;
— clinicians and other users of applications;
— informaticians, analysts and researchers working in the field of health information.

v
Technical Report ISO/TR 6231:2024(en)
Health informatics — Standardizing graphical content
1 Scope
This document describes the need for standardization of graphics and images in the health informatics
domain. It focuses on the current status of adoption and presents an overview of the opportunities as well as
challenges in creating sets of standardized images and graphics. A plan of action is proposed to serve as the
future roadmap for implementation.
2 Normative references
There are no normative references in this document.
3 Terms and definitions
For the purposes of this document, the following terms and definitions apply.
ISO and IEC maintain terminology databases for use in standardization at the following addresses:
— ISO Online browsing platform: available at https:// www .iso .org/ obp
— IEC Electropedia: available at https:// www .electropedia .org/
3.1 General terms
3.1.1
assessment in ankylosing spondylitis
ASAS
method to calculate disease activity score (3.1.3) for ankylosing spondylitis and related disorders
3.1.2
botulinum toxin
botox
product used to release spasm in certain neurological conditions
Note 1 to entry: Botox is also used in cosmetic surgery to erase fine wrinkles in the skin.
3.1.3
disease activity score
DAS
method to assess the disease activity
Note 1 to entry: DAS is commonly used for rheumatological disorders assessing specific problems in a few named
joints. In rheumatoid arthritis, 28 joints are assessed (DAS28), for SSA, the number of joints can be 44 (DAS44) or even
higher (DAS 66/68).
3.1.4
light amplification by simulated emission of radiation
laser
treatment used in cosmetic surgery for scars, pigmented lesions, and hair removal
3.1.5
lexicon
complete set of meaningful units in a language

3.1.6
medical device
instrument, apparatus, implement, machine, appliance, implant, reagent for in vitro use, software, material
or other similar or related article, intended by the manufacturer to be used, alone or in combination, for
human beings, for one or more of the specific medical purpose(s) of:
— diagnosis, prevention, monitoring, treatment or alleviation of disease;
— diagnosis, monitoring, treatment, alleviation of, or compensation for an injury;
— investigation, replacement, modification or support of the anatomy, or of a physiological process;
— supporting or sustaining life;
— control of conception;
— cleaning, disinfection, or sterilization of medical devices;
— providing information by means of in vitro examination of specimens derived from the human body;
and that does not achieve its primary intended action by pharmacological, immunological or metabolic
means, in or on the human body, but which can be assisted in its intended function by such means
[23]
[SOURCE: Essential Principles of Safety and Performance of Medical Devices and IVD Medical Devices ]
3.1.7
post-coordination
technique used in SNOMED CT (3.1.9) to combine clinical concepts (3.2.1) to ontologically define more
complex concepts
3.1.8
pre-coordinated expressions
expressions that represent the meaning of individual concepts (3.2.1) which are predefined in SNOMED CT (3.1.9)
3.1.9
SNOMED CT
Systemic NOmenclature in MEDicine Clinical Terms
systematically organized computer processable collection of medical terms providing codes, terms,
synonyms, and more, managed by SNOMED International
3.1.10
terminology
set of designations and concepts (3.2.1) belonging to one domain or subject
[SOURCE: ISO 1087:2019, 3.1.11]
3.1.11
training data set
data set of examples used during the learning process and used to fit the parameters
3.1.12
typeahead
method wherein a keyboard entry of the first few letters suggests the most likely word or phrase which will
complete the text
3.2 Terms related to information management
3.2.1
concept
unit of knowledge created by a unique combination of characteristics
Note 1 to entry: SNOMED CT (3.1.9) concept codes are numerical codes that identify clinical terms, primitive or defined,
organized in hierarchies.
[SOURCE: ISO 1087:2019, 3.2.7, modified — Notes to entry were removed; a new Note 1 to entry was added.]
3.2.2
coding scheme
collection of rules that maps the elements of one set on to the elements of a second set
[SOURCE: ISO/TS 21089:2018, 3.33]
3.2.3
data
information elements which are input, stored, processed or output by the automated information system
which supports the clinical and business functions of a healthcare (3.3.1) organization
Note 1 to entry: These data can relate to person identifiable records or be part of an administrative system where
persons are not identified.
[SOURCE: ISO/TS 21089:2018, 3.43]
3.2.4
electronic health record
EHR
health record (3.2.7) where all information is stored on electronic media
[SOURCE: ISO 13606-1:2019, 3.3.13]
3.2.5
electronic medical record
EMR
electronic record derived from a computerized system used primarily for delivering patient care in a
clinical setting
[SOURCE: ISO/TR 24291:2021, 3.3]
3.2.6
health information
information about a person relevant to his or her health
[SOURCE: ISO 18308:2011, 3.28]
3.2.7
health record
data (3.2.3) repository regarding the health and healthcare (3.3.1) of a subject of care
Note 1 to entry: The term electronic health record (3.2.4) may be used for a health record where all information is
stored on electronic media.
Note 2 to entry: A health record may include, for example, medical records, dental records, social care records.
[SOURCE: ISO 13606-1:2019, 3.3.11]
3.3 Terms related to healthcare
3.3.1
healthcare
care, services or supplies related to the health of an individual
Note 1 to entry: Includes any: a) preventative, diagnostic, therapeutic, rehabilitative, maintenance, or palliative
care, counselling, service, or procedure with respect to the physical or mental condition, or functional status, of
a patient or affecting the structure or function of the body; b) sale or dispensing of a drug, device, equipment, or
other item pursuant to a prescription; or c) procurement or banking of blood, sperm, organs, or any other tissue for
administration to patients.
[SOURCE: ISO 13940:2015, 3.1.1, modified — Original note to entry was removed; a new Note 1 to entry
was added.]
3.3.2
home healthcare
healthcare (3.3.1) provided in a dwelling place in which a care recipient lives or other places where care
recipients are present, excluding professional healthcare facility environments where operators with
medical training are continually available when care recipients are present
Note 1 to entry: Professional healthcare facilities include hospitals, physician offices, freestanding surgical centres,
dental office, freestanding birthing centres, limited care facilities, first aid rooms or rescue rooms, multiple treatment
facilities and emergency medical services.
Note 2 to entry: For the purpose of this document, nursing homes are considered dwelling places for home healthcare.
Note 3 to entry: Other places where a care recipient is present include the outdoor environments while working and in
vehicles.
[SOURCE: ISO/TR 25555:2024, 3.4]
3.3.3
telehealth
healthcare (3.3.1) activity supported at a distance by information and communication technology service(s)
Note 1 to entry: It is possible that the subject of care is not directly involved in a telehealth service, e.g. in the case of
tele-dermatology where one physician consults another physician who is at a distant location.
Note 2 to entry: Healthcare activities may include healthcare provider activities such as diagnosis, treatment, review
or advice, and self-care activities as prescribed or recommended by a health professional, preventive (educational)
advice and management of healthcare processes.
Note 3 to entry: Healthcare activities may include both synchronous (real-time) and asynchronous (delayed)
interactions between actors. For example, a radiology examination can be transmitted and subsequently reported
by a radiologist over a communications network. A discussion on the diagnostic findings can occur in real time over a
telephone or video conferencing connection between a patient and health professionals.
[SOURCE: ISO 13131:2021, 3.5.2, modified — The preferred term “ telehealth service” was changed to
“telehealth”.]
3.4 Terms related to graphical information
3.4.1
description
normative text which defines the purpose, the application and the use of the graphical symbol, and optional
product area
3.4.2
dragging
dragging and dropping
moving one (or more) object(s) on a display by translating it (them) along a path determined by a pointer
[SOURCE: ISO 9241-400:2007, 3.9.1]
3.4.3
frame
enclosing border or the matter or area enclosed in such a border, such as a picture
3.4.4
icon
digitized [pixelated (3.4.7)] representation of a graphical symbol, usually used on a reconfigurable electronic
display screen or graphical user interface (GUI)
Note 1 to entry: A single symbol can be represented by multiple icons, each of a different size, pixel count or colour.

[SOURCE: ISO 3767-2:2016, 3.2]
3.4.5
label
printed, written or graphic information placed on a medical device (3.1.6) or its container
[SOURCE: ISO 18113-1:2009, 3.33, modified — Notes were removed.]
3.4.6
pictogram
graphical composition that can include a symbol plus other graphic elements, such as a border, background
pattern or colour, and that is intended to convey specific information
3.4.7
pixel
smallest addressable element of a digital source image
[SOURCE: ISO/IEC 29112:2018, 3.1.21]
3.4.8
video graphics array
VGA
analogue display standard originally developed by International Business Machines (IBM)
Note 1 to entry: VGA uses 640 × 480 resolution.
4 Overview
Usage of informatics in healthcare along with telehealth is now a major component of health delivery. Given
the complexity of health-related information, the adoption of information technology in healthcare faces
obstacles from those with reading challenges. Illiteracy, poor understanding of health-related terminologies
as well as language differences have marred widespread adoption, creating a significant risk of adverse
outcomes. Better communication tools can help to circumvent such barriers. Graphical images can help ease
adoption and implementation of health information systems.
Although standardized images exist and enable rapid, non-verbal communication in domains such as
transportation and occupational safety, no analogous standards exist at present in health informatics.
Images and graphics facilitate communication across language and cultural barriers. To be used in health
informatics, it is important that they be readable and understood as easily as road signs which are used
universally. When used in electronic personal health records, they can improve health literacy and recall of
[16]
diagnostic information .
The complexity of healthcare terms, multiple meanings for the same term, and language and pronunciation
differences led to the creation of terminology standards like SNOMED CT. These clinical terminologies and
coding schemes, being vast and complex, require specialized skills to navigate and use. Graphics usage can
ease the navigation. The prerequisite is that standardized graphics and images have a firm linkage to the
related terminology or code. It is possible for an image to represent a unique identifier and map to one-to-
many terms which can be synonyms of each other. Over and above, despite there being over three million
terminologies within SNOMED CT, there still are many terms that need post-coordination. Graphical content
can ease finding the correct post-coordinated term.
Another issue in the implementation of terminologies is related to the challenge posed by language
differences. Language editions do address this issue, but not all languages can be covered. Even otherwise,
finding the correct term slows down data entry. Inbuilt spellcheck along with autocorrect, a part of many
applications, can create wrong or misunderstood terms. Images appearing alongside can allow for better
recall and correlation, besides correcting problems related to voice recognition, spelling, autocorrect and
typeahead solutions. While some images related to healthcare information are well defined, for example for
human anatomy, there are many intuitive symbols for abstract concepts which are yet to be standardized.
A surfeit of commercial imaging solutions is available, and also many free and open-source solutions. Some
[20,22]
ex
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