ASTM_E_2436_-_05_2010.pdf

Designation:E243605(Reapproved 2010)An American National StandardStandard Specification for theRepresentation of Human Characteristics Data in HealthcareInformation Systems1This standard is issued under the fixed designation E2436;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()indicates an editorial change since the last revision or reapproval.INTRODUCTIONThis document presents a standardized representation for the content and structure of humancharacteristics data for use in electronic health records and healthcare information systems generally.Many of the data available to clinicians,health researchers and educators,and healthcare plannerscannot be easily compared due to the variety in representing human characteristics.This documentstandardizes the representation of these characteristics at the data tier of health information systems.1.Scope1.1 This document presents a standardized representationfor the content and structure of human characteristics data foruse in healthcare information systems.1.2 This specification may be extended to apply to charac-teristics of non-human living things,such as in data systemssupporting veterinary medicine.1.3 The following provisions are within the scope of thisspecification:1.3.1 Logical representation of human characteristics datafor individuals and populations.1.3.2 Physical representation of human characteristics at thedata tier of healthcare information systems.1.4 The following provisions are outside the scope of thisspecification:1.4.1 The standardization of policy or regulation concerningthe employment of human characteristics data described in thisspecification.1.4.2 The establishment or standardization of legal con-straints over the use of human characteristics in conjunctionwith healthcare clinical or business processes.1.4.3 Addressing or standardizing personal privacy,medi-colegal,and system security provisions associated with docu-menting human characteristics or storing human characteristicsdata.1.5 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 limitations prior to use.2.Referenced Documents2.1 ASTM Standards:2E1384 Practice for Content and Structure of the ElectronicHealth Record(EHR)E1633 Specification for Coded Values Used in the ElectronicHealth RecordE2145 Practice for Information Modeling2.2ANSI StandardsANSI 260.3-1993 Mathematical Signs and Symbols for Usein Physical Sciences and Technology(revision and redes-ignation of ANSI/ASME Y10.20-1990).ANSI 1320.2-1998 IEEE Standard for Conceptual Model-ing Language-Syntax and Semantics for IDEF1X97(IDEFobject)ANSI/ADA 1000 Standard Data Architecture for the Struc-ture and Content of the Electronic Health Record,Febru-ary 2001.2.3ISO StandardsISO 639 Codes for the representation of names of languagesISO 2955 Representation of SI UnitsISO 5218 Representation of the Human SexesISO 8601 Representation of Dates2.4 Other Standards and DocumentsAmerican Heritage DictionaryANSI/ADA Specification 1000 Implementation GuideHL7 2.x reference values.1This specification is under the jurisdiction of ASTM Committee E31 onHealthcare Informatics and is the direct responsibility of Subcommittee E31.25 onHealthcare Data Management,Security,Confidentiality,and Privacy.Current edition approved June 1,2010.Published September 2010.Originallyapproved in 2005.Last previous edition approved in 2005 as E243605.DOI:10.1520/E2436-05R10.2For referenced ASTM standards,visit the ASTM website,www.astm.org,orcontact ASTM Customer Service at serviceastm.org.For Annual Book of ASTMStandards volume information,refer to the standards Document Summary page onthe ASTM website.Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,PA 19428-2959.United States1 National Institute of Standards and Technology,FederalInformation Processing Standards Publications 184 Inte-grated Definition for Information Modeling(IDEFIX),23December 1993.3.Terminology3.1 Acronyms:ADA=American Dental AssociationANSI=American National Standards InstituteCCR=ASTM standard Continuity of Care RecordHL7=Health Level SevenIDEF=Integrated Definition languageISO=International Standards OrganizationLDM=Logical data modelLOINC=Logical Observation Identifiers Names and CodesPDM=Physical data modelXML=Extensible Markup Language3.2 Definitions:3.2.1 Ethnicity,ncharacteristics of a group of peoplesharing a common and distinctive racial,national,religious,linguistic,or cultural heritage.American Heritage Dictionary3.2.2 Language,nA system of arbitrary signals,such asvoice sounds,gestures,or written symbols,including its rulesfor combining its components,such as words,as used by a