Standards Knowledge Management Tool Glossary Harmonisation

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Standards Knowledge Management Tool Glossary
Harmonisation

• Heather Grain
• ISO
• Durham
• October 2009

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Objective

• To consider terms with multiple definitions and
  clarify context / preferred definition.

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Terminology - Definitions

• A set of concepts designated by terms belonging
  to a special domain of knowledge, or subject
  field .
• A set of terms representing a system of concepts
  within a specified domain
• A set of designations within a subject field
• A set of terms belonging to one special language
• A set of designations belonging to one special
  language
• A defined or limited vocabulary of terms or
  concepts.

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Terminology examples/notes

• A terminology is not an arbitrary collection of
  terms, but a collection of designations
  attributed to concepts making up the knowledge
  structure of a subject field. The concepts of a
  well-structured terminology should constitute a
  coherent collection based on the relations
  established between concepts. The meaning of each
  concept within a system can be determined by the
  intension, i.e. the unique set of characteristics
  constituting the concept, or its extension, i.e.
  the enumeration of the subordinate concepts of a
  concept. Most terminologies can be classified as
  either reference terminologies or interface
• A terminology can be seen as a kind of ontology.
  An ontology has all the characteristics of a
  terminology, but it also uses a methodology for
  the description of the relationships between
  concepts (e.g., Description Logic) which allows
  humans and (depending on the methodology)
  machines to reason about the properties of that
  subject domain and to deduce knowledge from the
  way the concepts relate to each other.
  Ontologies allow different types of concept
  relationships to capture their richness.
  Hierarchical terminologies can be seen as
  rudimentary ontologies as they describe the
  relationships of concepts to each-other but have
  only one type of relationship.
• Terminology generally refers to the family of
  reference terminology, interface terminology and
  aggregate terminology.
• Guide for use This term should not be used
  without clarification of meaning and context.
  For the application of terminology in informatics
  see Reference terminology, Interface terminology
  and Aggregate terminology.

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Vocabulary - definition

• The set of valid values for a coded attribute or
  field
• terminology is used when computing, and
  vocabulary is more general than terminology and
  not necessarily represented in computable forms.
• There are statements that vocabulary is a synonym
  for terminology this is not consistent with use.

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Reference Terminology - definition

• A terminology in which every concept designation
  has a formal, machine-usable definition
  supporting data aggregation and retrieval.
• A terminology designed to uniquely represent
  concepts. It does this by listing the concepts
  and specifying their structure, relationships
  and, if present, their systematic and formal
  definitions.
• A set of atomic level designations structured to
  support representations of both simple and
  compositional concepts independent of human
  language (within machine)

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Reference Terminology examples/notes

• It normally contains a unique identifier, a
  rubric and may contain reference to alternate
  terms to the preferred term (which may be
  conceptualised as an interface term (interface
  terminology) and it may contain maps or pointers
  to aggregate terminology
• Interface terminology may use terms such as
  Chest Pain 1 (which has a local meaning) while
  the reference terminology would include the
  recognized common term myocardial infarction.
• The hub of terminology. Interface and aggregate
  terminologies both relate directly to the
  reference terminology.
• In the reference terminology the unique concepts
  are described by their preferred (or canonical)
  terms along with all the allowable terms. It
  allows for local expressions in interface
  terminologies to be used as long as the interface
  terms are mapped correctly to the concepts and
  preferred terms in the underlying reference
  terminology.

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Interface Terminology - definition

• A maintained set of unique identified terms
  designed to be compatible with the natural
  language of the user.
• used to mediate between a users colloquial
  conceptualizations of concept descriptions and an
  underlying reference terminology.

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Interface Terminology examples/ notes

• Interface terminologies can be proprietary or in
  the public domain e.g., MEDCIN or more academic
  ones like ORCA, PENPAD, or LOCAS
• Used to enter information into a health
  information system. The terms can vary from site
  to site and specialty to specialty, so that
  familiar terms can be used to say exactly what
  users mean in their operational contexts.
  Interface terms may be linked to the underlying
  concepts in a reference terminology, which then
  serve as an interlingua to trace identical
  concepts from one interface terminology to
  another.
• These links are also important to trace concepts
  from the interface terminology to the aggregating
  terms used to get comparable data for aggregation
  and analysis. In this context, those responsible
  for each information system need to maintain the
  mapping only to the reference terminology.

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Classification - definitions

• Synonym taxonomy , reporting terminology
•  
• An exhaustive set of mutually exclusive
  categories to aggregate data at a pre-prescribed
  level of specialization for a specific purpose
• A terminology which aggregates data at a
  prescribed level of abstraction for a particular
  domain
• A terminological concept system connected by
  generic relations
• The categorization of relevant natural language
  for the purposes of systematic analysis.
• A type of aggregating terminology, is a logical
  system for the arrangement of knowledge. A fully
  developed classification scheme specifies
  categories of knowledge and provides the means to
  relate the categories to each other and to
  specify in the classification number all or the
  most important of the aspects and facets of a
  subject.
• Context of Electronic Health Record Architecture
• Systematic identification and arrangement of
  business activities and/or records i.e. data
  into categories according to logically structured
  conventions, methods, and procedural rules
  represented in a classification system.

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Classification example / notes

• This fixing of the level of abstraction that can
  be expressed using the classification system is
  often done to enhance consistency when the
  classification is to be applied across a diverse
  user group, such as is the case with some of the
  current billing classification schemes.
• Classifications often have less granular concepts
  than terminologies and may lack concept codes.
• To be used as vocabularies in HL7,
  classifications need to have concept codes and
  must contain concepts at an adequate level of
  granularity. Like hierarchical terminologies,
  however, classifications often specify
  hierarchical parent-child relationships

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EHR definitions - types

• Medical Record (or Health Record)
• Digitized Medical Record (Scanned Medical Record)
• Basic (all inclusive EHR) (includes scanned
  medical records and computable, and shareable)
• Computable EHR has atomic data components.
• Shareable EHR has standardised model
• Personal Health Record maintained by the
  individual

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Health Record

• A collection of data and information gathered or
  generated to record clinical care rendered to an
  individual.
• Suggestion move from EHR to Health Record

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Medical record

• A health record maintained by a medical
  organisation

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Digitized Health Record

• Health record concerning the subject of care in
  computer-readable form
• A healthcare record in computer readable format

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EHR

• Repository of information regarding the health of
  a subject of care, in computer processable form.
•  
• Repository of information regarding the health
  status of a subject of care, in computer
  processable form
• Comment not just health status
• Notes
• That EHRs include health status information.
• The definition of the EHR for integrated care is
  considered to be the primary definition of an
  electronic health record. The definition of a
  basic-generic EHR is given only for completeness
  and to acknowledge that there are still currently
  many variants of the EHR in health information
  systems which do not comply with the main (ICEHR)
  EHR definition (e.g. a CDR complies with the
  basic-generic EHR definition but not with the
  ICEHR definition).
• Includes digitised and all forms of EHR

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Computable EHR

• include concepts of
• Longevity
• Single individual
• Creation, import, store, use
• Created by health care providers, patients and
  carers

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Computable EHR definition

• Any longitudinal, patient-centred medical record
  in stored and accessible in an electronic format
• A comprehensive, structured set of clinical,
  demographic, environmental, social, and financial
  data and information in electronic form,
  documenting the health care given to a single
  individual.
• Comment it is not just health care given it is
  also status and comment information.
• A longitudinal collection of personal health
  information of a single individual, entered or
  accepted by health care providers, and stored
  electronically. The record may be made available
  at any time to providers, who have been
  authorised by the individual, as a tool in the
  provision of healthcare services. The individual
  has access to the record and can request changes
  to its contents. The transmission and storage of
  the record is under strict security.
• Comment this definition has comments on access
  and control, are these essential definitional
  components, or are the comments on use?
• a virtual compilation of non-redundant health
  data about a person across a lifetime, including
  facts, observations, interpretations, plans,
  actions, and outcomes. Health data include
  information on allergies, history of illness and
  injury, functional status, diagnostic studies,
  assessments, orders, consultation reports,
  treatment records, etc. Health data also include
  wellness data such as immunization history,
  behavioural data, environmental information,
  demographics, health insurance, administrative
  data for care delivery processes, and legal data
  such as consents.
• an electronic patient record that resides in a
  system designed to support users through
  availability of complete and accurate data,
  practitioner reminders and alerts, clinical
  decision support systems, links to bodies of
  medical knowledge, and other aids
• Comment action focused definition, could be
  about other than patients.

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Shareable EHR

• An electronic record for healthcare providers to
  create, import, store and use clinical
  information for patient care, according to
  nationally recognised interoperability standards.
• Note the EHR has the following distinguishing
  features able to be obtained from multiple
  sources shareable interoperable, accessible to
  authorised parties.
• Comment these records do not only include
  clinical information. Are statements such as a
  requirement for longevity
• electronic health record with a standardized
  information model which is independent of
  electronic health record systems and accessible
  by multiple authorized users
• Comment if EHR is defined and EHR system is
  defined, this is a good general description
• EHR with a commonly agreed logical information
  model

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Personal Health Record

• An electronic longitudinal collection of personal
  health information, usually based on the
  individual, entered or accepted by health care
  providers, which can be distributed over a number
  of sites or aggregated at a particular source.
  The information is organised primarily to support
  continuing, efficient and quality healthcare.
  The record is under control of the consumer and
  is stored and transmitted securely
• Consideration of patient/carer input