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ASTM E1633-08
Standard Specification for Coded Values Used in the Electronic Health Record
84 стр.
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Разработчик:
Зарубежные/ASTM
ICS:
35.240.30 IT applications in information, documentation and publishing. Including Standard Generalized Markup Language (SGML), automatic translation machines, etc. / Применение информационных технологий в области информации, документации и в издательском деле. Включая стандартный обобщенный язык разметки (SGML), машины автоматического перевода и т.д.
Сборник (ASTM):
14.01 Healthcare Informatics / Информатика в области здравоохранения
Тематика:
Computerized Systems
Описание
Значение и использование

PurposeThe approval of Guide E 1384, concerned with the structure and content of the computer-based patient record, now includes a formal indexing of data elements and a cataloging of the minimal essential value set for these elements. Indexing of these data elements with a unique identifier keyed to its position in the logical structure of Appendix X1 of Guide E 1384 now provides a means of cataloging the value sets representing each data element (see Guide E 1384). Specification E 1238, coordinated with Guide E 1239, describes conventions for representing many of the data values for data elements that are included in the more comprehensive listing in Guide E 1384. A comprehensive listing of all of the value sets associated with Guide E 1384 has not yet been assembled. This specification begins to catalog the representation conventions for a number of these elements and in particular to list the coded values. It is important that this catalog consider the traditionally assigned representations for each of these elements, and it must resolve differences in a manner that introduces systematics and consistency into the representation. The catalog must establish both a global framework consistent with international standardization and with long-term growth, while at the same time maximizing familiar or traditional representations. This standard has been developed with input from many organizations, including government agencies and other standards bodies and professional associations, and as a result of the effort to achieve consistency and comprehensiveness among the data dealt with by various standards efforts.

General ValuesEarly in the coordination of healthcare information standards an informal body, the Healthcare Information Standards Coordinating Committee (HISCC), identified certain common data element types and agreed upon conventions for representing these data element types in a standard manner. This set the stage for the development of the value sets for the CODED VALUE data type. The status of the standard noncoded data types, and their representations, agreed upon by the HISCC are:

Person NamesSpecification E 1238, Guide E 1239, Practice E 1715, Practice E 1744, and HL-7 use the same representation for American and European forms.

AddressesCommon format in Specification E 1238, Guide E 1239, Practice E 1715, and Practice E 1744. .

Telephone NumbersSpecification E 1238 and Guide E 1239 currently use the same representation with area code enclosed in parentheses and country code preceding the parentheses.

DatesDate and time represented as ANS X3.51-1986/ISO 8601-1988 with years in four digits; time not separated from date by T as permitted by ISO 8601.

NumbersNumbers are represented either as integers or fixed point numbers; exponential notation not presently accepted in Specification E 1238, Guide E 1239, or HL-7. Units of Measure by ISO 2955-1983 or ANS X3.50-86.

Strings7-bit ASCII characters; multilingual character sets not yet defined.

Область применения

1.1 This specification covers the identification of the lexicons to be used for the data elements identified in Appendix X1 of Guide E 1384. It is intended to unify the representations for: (1) primary record of care data elements, (2) the data elements identified in other standard statistical data sets, (3) data elements used in other healthcare data message exchange format standards, or (4) in data gathering forms for this purpose, and (5) in data derived from these elements in order that data recorded in the course of patient care be exchangeable and be the source of accurate statistical and resource management data. This specification is applicable to all paper and automated systems.

Ключевые слова:
Pharmaceutical industry--computer systems; Physicians; Structure (computer applications); Records management; Religious classification; Remote laboratories; Transfer (of data)--specifications; Transmission; Two-way digital transmission; Admissions; Automated primary record of care; Bed control; Clinical codes/signs; Coded values; Communications (medical applications); Computerized clinical laboratory systems; Computerized systems--specifications; Diagnosis; Digital transmission; Discharge data; Electronic health record (EHR); Emergency medical services (EMS)--specifications; Ethnicity; Healthcare documentation/delivery/training--specifications; Inpatient health care; Lexicons; Medical materials/applications--specifications; Nationality/country of origin; Patient biographical/medical data--specifications