ASTM E2457-07(2013) - 1.3.2013
 
Significance and Use

3.1 This standard vocabulary is intended to be used as a reference about terms used in standards for healthcare informatics and in general discussions about informatics issues relating to the healthcare sector, including: clinical care, resource management, policy, clinical or health services research or biomedical research in basic or applied areas of science that refer to the healthcare sector. It contains “Elected Terms” rather than the “Preferred” terms used in the terminologic literature. This is a usage coined within the CEN TC-251 community to reflect the fact that there is consensus agreement on the usage of a particular form rather than an imposition. This consensual agreement to usage better reflects the incentives for common usage rather than mandates. Alternate forms (Synonymy) of an elected term exist and are cataloged for the same concept, in accordance with ISO/DIS 1087-1, ISO 704, ISO 12620, and EN-12017, ISO/DIS 860, EN-12264, and ANSDIT.

3.2 The system used to classify these terms is in the full context of all of the terminology of biomedicine, as well as about the healthcare system itself as it is used throughout the health domain. It has drawn on the terms used in both EN-12017 and in UMLS for biomedicine (Guide E1284, Specification E1633, ISO 12200, GALEN). The coding scheme described in Section 5 used to represent this classification was developed for this terminology from the Unified Medical Language System documentation produced by the National Library of Medicine.

 
1. 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.

 
2. Referenced Documents

E1384-07

Standard Practice for Content and Structure of the Electronic Health Record (EHR)

E1762-95

Standard Guide for Electronic Authentication of Health Care Information

E1869-04

Standard Guide for Confidentiality, Privacy, Access, and Data Security Principles for Health Information Including Electronic Health Records

E1284-97

Standard Guide for Construction of a Clinical Nomenclature for Support of Electronic Health Records (Withdrawn 2007)

E1239-04

Standard Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems

ISO/DIS 860

International Harmonization of Concepts and Terms

E1986-09

Standard Guide for Information Access Privileges to Health Information

ISO 704

Principles and Methods of Terminology

EN-12264

Categorical Structure of Syntax of Concepts--Model for Representation of Semantics (MOSE)

EN-12017

Medical Informatics Vocabulary (MIVoc)

E2147-18

Standard Specification for Audit and Disclosure Logs for Use in Health Information Systems

E2087-00

Standard Specification for Quality Indicators for Controlled Health Vocabularies (Withdrawn 2009)

E1987-98

Standard Guide for Individual Rights Regarding Health Information (Withdrawn 2007)

E1985-98

Standard Guide for User Authentication and Authorization

ISO 12200

Terminology--Computer Applications--Machine Readable Terminology Interchange Format

ISO 15188

Project Management Guidelines for Terminology Interchange Format

ISO 12620

Terminology--Computer Applications--Data Categories

ISO/IEC 12207

Life Cycle Processes

ISO 10241

Terminology--Standards Representation and Layout

ISO 2382/4

Information Technology--Vocabulary--Organization of Data

ISO/DIS 1087-2

Terminology--Vocabulary--Part 2 Computer Applications

ISO/DIS 1087-1

Terminology--Vocabulary--Part 1 Theory and Application

E1633-08

Standard Specification for Coded Values Used in the Electronic Health Record