ASTM-E1633:2008 Edition(Redline)

This specification covers all paper and automated systems related to the identification of the lexicons to be used for the data elements 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 abstract is a brief summary of the referenced standard. It is informational only and not an official part of the standard; the full text of the standard itself must be referred to for its use and application. ASTM does not give any warranty express or implied or make any representation that the contents of this abstract are accurate, complete or up to date.

Significance and Use

Purpose — The 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 Values — Early 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 Names — Specification E 1238, Guide E 1239, Practice E 1715, Practice E 1744, and HL-7 use the same representation for American and European forms.

Addresses — Common format in Specification E 1238, Guide E 1239, Practice E 1715, and Practice E 1744. .

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

Dates — Date 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.

Numbers — Numbers 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.

Strings — 7-bit ASCII characters; multilingual character sets not yet defined.

1. Scope

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.

2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.

ASTM Standards

E1238 Specification for Transferring Clinical Observations Between Independent Computer Systems E1239 Practice for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems E1384 Practice for Content and Structure of the Electronic Health Record (EHR) E1715 Practice for An Object-Oriented Model for Registration, Admitting, Discharge, and Transfer (RADT) Functions in Computer-Based Patient Record Systems E1744 Practice for View of Emergency Medical Care in the Electronic Health Record

ANSI Standards

ANSX3.51 Representation of Common Units

ISO Standards

ISO8601 Representation Dates

Other Standards

HL-7 Health Industry Level 7 Interface Standards Available from Health Level 7, Mark McDougall, Executive Director, 900 Victors Way, Suite 122, Ann Arbor, MI 48108.

Keywords

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; Pharmaceutical industry–computer systems; Physicians; Records management; Religious classification; Remote laboratories; Structure (computer applications); Transfer (of data)–specifications; Transmission; Two-way digital transmission;

ICS Code

ICS Number Code 11.020 (Medical sciences and health care facilities in general); 35.240.30 (IT applications in information, documentation and publishing)

DOI: 10.1520/E163