ASTM_E_2182_-_02.pdf

Designation:E 2182 02An American National StandardStandard Specification forClinical XML DTDs in Healthcare1This standard is issued under the fixed designation E 2182;the number immediately following the designation indicates the year oforiginal adoption or,in the case of revision,the year of last revision.A number in parentheses indicates the year of last reapproval.Asuperscript epsilon(e)indicates an editorial change since the last revision or reapproval.1.Scope1.1 This specification defines an electronic representationthat includes the varying information required for broadexchange in health care both today and in the future.eXten-sible Markup Language(XML)is a convergence of dataprocessing,communication,and publishing technology.XMLis a platform,vendor,and application independent technologyfor describing document content and structure in tags orelements.The names of the tags and the rules for using themare contained in the Document Type Definition(DTD).TheDTD describes the structure of the document and defines thenames of tags it contains.Additionally the DTD declares theorder in which the tags occur and how often the tags canappear;that is,the DTD defines the hierarchy of the tags.ADTD for a prescription might contain structural elements forthe medication prescribed,the dosage,the form,the quantity,and so forth.Thisspecification is in the form of a set of standard XMLDTDs thatmatch the electronic document requirements in the health careindustry.1.2 This specification refers to and makes use of recommen-dations from the World Wide Web consortium,the W3C(http:/www.w3.org).1.3 This standard does not purport to address all of thesafety concerns,if any,associated with its use.It is theresponsibility of the user of this standard to establish appro-priate safety and health practices and determine the applica-bility of regulatory requirements prior to use.2.Referenced Documents2.1 ASTM Standards:E 1239 Guide for Description of Reservation/Registration-Admission,Discharge,Transfer(R-ADT)Systems forAutomated Patient Care Information Systems2E 1384 Guide for Content and Structure of the ElectronicHealth Record(EHR)2E 1633 Specification for Coded Values Used in the Elec-tronic Health Record2E 2183 Guide for XML DTD Design,Architecture andImplementation22.2W3C World Wide Web Consortium Recommendations,(http:/www.w3.org)XML 1.0 Recommendation,http:/www.w3.org/TR/REC-xmlXHTML Basic Recommendation,http:/www.w3.org/TR/xhtml-basicXML Linking(Xlink)1.0 Recommendation,http:/www.w3.org/TR/xlinkXML Namespaces Recommendation,http:/www.w3.org/TR/REC-xml-namesXPointer,http:/www.w3.org/TR/xptrXSLT,http:/www.w3.org/TR/xslt2.3HL7 Standards,(http:/www.HL7.org)Informative Document:Using XML as an Alternative Mes-sage Syntax for HL7 Version 2.3.xClinical Document Architecture:Level 12.4IETF Specifications,(http:/www.ietf.org)RFC 2396:Uniform Resource Indentifiers(URI),http:/ietf.org/rfc/rfc23963.Terminology3.1 Definitions:3.1.1 clinical document,ndefined in terms of the nativeXML architecture.The Document Type Definition(DTD)isthe base method of defining the structure of a clinical docu-ment.XML schema languages such as the W3C XML SchemaLanguage and the OASIS RELAXNG Schema language pro-vide alternative methods of defining clinical document struc-tures.3.1.2 document type definition(DTD),nthe formal defi-nition of the elements,structures,and rules for enablingplatform independent data access via XML or for marking upa given type of SGML document.3.1.3 extensible markup language(XML),na standardfrom the World Wide Web Consortium(W3C)that provides fortagging of information content within documents,offering ameans for representation of content in a format which is bothhuman and machine readable.Through the use of customizablestyle sheets and schemas,information can be represented in a1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.28 onElectronic Healthcare Records.Current edition approved Jan.10,2002.Published March 2002.2Annual Book of ASTM Standards,Vol 14.01.1Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959,United States.uniform way,allowing for interchange of both content(data)and format(metadata).3.1.4 Health Level 7(HL7),na standards organizationtraditionally focused on message-oriented standards for health-care.HL7 messages are the dominant standard for peer-to-peerexchange of clinical,text-based information.HL7 has recentlyintroduced a document-oriented standard,the Clinical Docu-ment Architecture.3.1.5HL7 clinical document architecture(CDA),ntheHL7 CDAis a document markup standard for the structure andsemantics of exchanged clinical documents.A clinical docu-ment is a documentation of observations and other serviceswith the following characteristics:Persistence,Stewardship,Potential forAuthentication,Wholeness,and Human Readabil-ity.A clinical document is a defined and complete infor