ISO TC 215/SC N - Mayo Clinic



COMMITTEE DRAFT© ISO 2010 – All rights reservedISO/PDTR  16 Mapping of Terminologies to Classifications Mapping of Terminologies to ClassificationsE2010-01-10(30) CommitteeISOISO  Technical Report2010 ISO/TR ISO/TR ISO/PDTR  ANSI Health Informatics3 215 2Heading 2Heading 1 02 STD Version 2.1c230 4U:\Standards\TC215\N804\isotc215wg3_N505_ISO_DTR 12300_Mapping of Terminologies to Classifications(E) v0.1.doc ISO TC 215/SC  N 

Date:   2010-05-31

ISO/PDTS 

ISO TC 215/SC /WG 3

Secretariat:   ANSI

Development of terms and definitions for the Health Informatics Glossary

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Contents Page

Foreword iv

1 Introduction 1

1.1 General Introduction 1

1.2 Business Need 1

2 Scope 2

2.1 General Scope 2

2.2 Audience 2

3 Terms and Definitions 2

3.1 abbreviation 2

3.2 context 2

3.3 synonym 2

3.4 term 3

3.5 term family 3

3.6 Related Documents 3

4 Principles Rules and Content 3

4.1 Overview 3

4.2 Term 4

4.3 Term Definition 5

4.4 Context 5

4.5 Source 5

4.6 Usage Comment 5

4.7 Image 5

4.8 Document/s in which the term/definition is used 6

4.9 Category 6

4.10 Version 6

4.11 Version Date 6

4.12 Rationale for change 6

Foreword

ISO (the International Organization for Standardization) is a worldwide federation of national standards bodies (ISO member bodies). The work of preparing International Standards is normally carried out through ISO technical committees. Each member body interested in a subject for which a technical committee has been established has the right to be represented on that committee. International organizations, governmental and non-governmental, in liaison with ISO, also take part in the work. ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of electrotechnical standardization.

International Standards are drafted in accordance with the rules given in the ISO/IEC Directives, Part 2.

The main task of technical committees is to prepare International Standards. Draft International Standards adopted by the technical committees are circulated to the member bodies for voting. Publication as an International Standard requires approval by at least 75 % of the member bodies casting a vote.

In exceptional circumstances, when a technical committee has collected data of a different kind from that which is normally published as an International Standard (“state of the art”, for example), it may decide by a simple majority vote of its participating members to publish a Technical Report. A Technical Report is entirely informative in nature and does not have to be reviewed until the data it provides are considered to be no longer valid or useful.

Attention is drawn to the possibility that some of the elements of this document may be the subject of patent rights. ISO shall not be held responsible for identifying any or all such patent rights.

ISO/TR  was prepared by Technical Committee ISO/TC 215, Health Informatics, Subcommittee SC , .

This second/third/... edition cancels and replaces the first/second/... edition (), [clause(s) / subclause(s) / table(s) / figure(s) / annex(es)] of which [has / have] been technically revised.

Development of terms and definitions for the Health Informatics Glossary

Introduction

1 General Introduction

There are many national and international efforts to write and use clear standards to support the development of electronic health care initiatives. There are many standards and terms defined, however finding the relevant standard, recording suggested improvements and encouraging the use of standards is an ongoing issue to all involved in the development of these documents and in their use. An associated problem has been identified in Health Informatics publications where increasingly terms are defined and/or used in different ways. This situation leads to a lack of clarity in the use and meaning of health informatics around the world including in Standards.

This document identifies best practice in writing definitions for health informatics concepts, and the metadata used to reference these concepts in the shared online tool of the Joint Initiative Council of Health Informatics Standards Development Organisations, the Standards Knowledge Management Tool Glossary ()

The Standards Knowledge Management Tool is an internet based tool designed to assist in finding and managing standards documents, products, terms and s. Each term and associated definition can be linked back to the document/s within which it is used (even if that link is simply to an organizations glossary).

2 Business Need

This work stems from three needs:

a) To improve communication and understanding within the international health informatics community, within and outside the standards environment. Consistent and clear use of terms and understanding of the definitions of these terms can significantly enhance the ability for health informatics programs around the world to deliver their required outcomes. Open availability of this information in a quick and simple manner can reduce confusion and encourage both the use of standards and the appropriate use of language within the community, thereby increasing re-usability and information sharing.

b) To improve and simplify the standards development process by giving assess to existing definitions, thereby encouraging harmonisation (or the movement towards a single definition or the clear statement of the context within which a specific alternative definition applies). There is also a need to be able to identify the terms in a given document and to update them to agreed definitions over time. A great deal of standards development is done by volunteers, and the SKMT Glossary provides to assist them in finding and using quality definitions.

c) To enhance the standing of the standards community by providing clear guidance on terms to be used, This represents leadership of the community through provision of a public good as well as a tool to assist their own operations.

Scope

1 General Scope

This Technical Specification provides details of the metadata and requirements for quality terms and definitions in health informatics glossaries, and in particular those entered into the Standards Knowledge Management Tool Glossary. The guidance is based upon that provided in ISO-IEC 2382-1 Information Technology Vocabulary Fundamental Terms.

2 Audience

• Health Informatics Standards Developers and Standards Development Organisations

• Developers, implementers and managers of health information systems, clinical information systems and clinical decision support systems

• All users of health information systems clinical data, such as health statisticians, researchers, public health agencies, health insurance providers, health risk organisations, data analysts and data managers

Terms and Definitions

Drafting Note: This document includes information that will be removed in the document, but that are necessary to progress term/definition decision making. Such information includes the information in boxes – rationale to suggested harmonised solution, and multiple definitions, the requirement is for a single definition.

Where there are terms used in this document that are not defined in this section, they are considered to be generic to the English language and not specific to this document. Additional definitions and terms can be found at the international health informatics Standards Knowledge Management Tool and Glossary website

1 abbreviation

A shortened form of a written word or phrase used in place of the whole

Example: HL7 is an abbreviation of Health Level Seven

Source: Webster’s Dictionary

3.1 concept harmonization

activity leading to the establishment of a correspondence between two or more closely related or overlapping

concepts having professional, technical, scientific, social, economic, linguistic, cultural or other differences, in

order to eliminate or reduce minor differences between them

NOTE The purpose of concept harmonization is to improve communication.

2 context

Related conditions and situations that provide a useful understanding and meaning of a subject

Source: ISO/TR 17119:2005

3 synonym

one of two or more words or expressions of the same language that have the same or nearly the same meaning in some or all senses

Source: Webster’s Dictionary

4 term

Linguistic representation of a concept

5 term family

A group of concepts which are related and by defining one part of that group, assist in the definition of the other members of the group

Example: Health record, healthcare record, electronic health record. The health record could be considered the least specific, healthcare records relate not to health in any context, but to the care provided in relation to health (and could be considered a synonym of medical record, while electronic health record implies a format or functionality of the health record. Once health record is defined, it is easier to define healthcare record, and electronic health record, as it is not necessary to define the base from which the definition begins.

6 Related Documents

ISO 860-2007 Terminology work – Harmonization of concepts and terms

ISO 1087-1:2000 Terminology work – Vocabulary – Part 1: Theory and application

ISO 704-009 Terminology work – Principles and methods

ISO/IEC 2382-1:1993 Information Technology Vocabulary Fundamental Terms

Principles Rules and Content

1 Overview

A term may occur many times, each time with different identifying characteristics. These characteristics include the definition of the term, the context in which that definition applies, examples and comments on the use of the term.

Some terms may not have definitions but may simply be synonyms of other terms. A single term might exist as a synonym, and as a term with a specific definition. The design of the glossary supports recording of terms and their identifying information (metadata) as they are in the real world. This approach requires a facility to record all of these permutations of complexity and inconsistency. As the terms have been used in existing standards the ability to record and eventually manage this complexity is a major requirement of the a glossary.

The glossary supports clarification and improved conformance in the use of terms and their definitions within standards documents.

The implication of this approach is that the glossary will initially have many duplication and contradictions and that these will be progressively resolved. Resolution will lead to some terms being declared as Standards (the preferred definition and term) and others being retired. Retirement does not remove the term from the glossary, and the fact that the term exists in a Standards document will continue to be acknowledged, however the term and associated metadata will clearly be declared as ‘out of date’ and point to the agreed Standard term and definition which is to be used when standards are re-issued or reviewed. This process encourages an ongoing improvement and resolution of terms throughout all health informatics standards. For further information on the management process and content refer to ISO work item on “Common Glossary” and “Standards Knowledge Management Tool”.

This document does not over ride the requirements for presentation of glossary information in the documents of individual Standards Development Organisations, however it provides additional guidance to support clarity and harmonisation.

The glossary tool offers functionality including:

• Retrieval of terms/definitions from within documents created by a given organisation or working group (to support document revision and review)

• Simple linking of existing terms/definitions to new or updated documents in a single process.

• Searching for terms by a range of criteria

• Term management, including merging of definitions, definition retirement, correction of term and definition spelling.

• Marking of terms or documents in which you have an interest (any modifications will be notified to your email address automatically.

• Extraction of individual organisational glossary.

This document does not define all requirements of a glossary, as these are defined elsewhere, but it does identify specific rules and principles identified through review of the content of existing glossaries that will improve the quality and consistency of all entries. Within the SKMT Glossary a term exists only once, but may have many definitions. The metadata associated with glossary definitions belong to the definition not to the term.

No organisation or standard ‘owns’ a term. Definitions are linked to documents which are owned, or created by standards development organisations. In the SKMT Glossary tool organisations can determine ‘their’ definitions and create their own glossary by searching by organisation for terms linked to their documents. The processes of the SKMT Glossary are not defined here, as they are provided in detail in the User Guide.

2 Term

The word or group of words being defined. This is a required element and should include any term that would normally be included in a terms/definitions or glossary section of a document or product.

A term is mandatory and should be:

• a word or group of words

• written in full,

• singular

• use sentence case for all terms (leading capital then lower case throughout)

• positive rather than negative, though negative concepts may be included if essential to clear meaning.

For example:

• policy - not policies,

• electronic health record – not EHR.

• The name of an organisation should be a term written in full and the definition a description of that organisation, while the abbreviation or acronym of the organisation should be listed as a synonym of the full name.

Terms may be defined in different languages. Where required alternative forms of English may be indicated as specific languages e.g.: US English is not the same as English.

The term is the preferred term in the language being used, synonyms, related terms and abbreviates can also be included but are not the ‘core’ term.

3 Term Definition

A term may have many definitions, but it is preferred that there be one definition for a term in any given context. The definition is a textual description of the meaning of the term. Images may be included to more clearly describe what it intended. These are held in the Image section of the glossary.

Where a concept is to be defined, this should be done in consideration of not only this term but other terms to which this term relates. For example: do not define electronic health record, alone. To accurately define this concept is necessary to understand the ‘family’ to which it belongs. The electronic health record family could include health record, healthcare record, medical record, person health record. The ‘term family’ should be defined as a group rather than individually as the understanding and consistent definition of the whole, significantly improves the understanding and utility of the individual members of the family.

The definition should

• Not include the term or its synonym/s or abbreviations or other forms (noun instead of verb) in the definition

• Use dictionary style. Phrases such as “Word means” or “This describes a situation in which” may get you started but should be edited out of your final definition.

• Write the definition to match the part of speech. If a verb the definition will probably begin with ‘to’. Nouns are likely to begin with ‘a’ or ‘the’.

• The definition should define the concept, while the Usage Comment should give examples, and describe in more detail what is meant. Do not include long rambling examples, or inclusions in the definition as this will make harmonisation more difficult.

• Use simple language. Where there is a highly complex definition used by a specialist area of the community, this should be given the context – Formal (as in formal definition), while the simple plain language version of the definition should be the one used as the ‘core definition’ the one used across all contexts not declared.

4 Context

The situation or organisation to which this definition of the term applies. This is also called specialisation context. This is a free text field that is required to differentiate between multiple standard (category) definitions of a single term.

Context should only be included if this definition of the term is for a specific purpose and not applicable throughout all areas of health informatics. Context should be described clearly and an example should be provided to ensure intelligibility to all readers, recognising that not all readers are technical or specialists in the area concerned.

5 Source

This is a reference to the original source of the definition, which may or may not be in a Standard. This does not mean just the document in which the definition is used, as there may be many of these, but the original source of the definition where it is known. Source is optional, when it is not known it should be left blank.

6 Usage Comment

Description of how this term is used, including examples and notes. This is free text, may be blank and may included comments from more than one Standards Development Organisation.

7 Image

This is an optional PDF format image which enhances or explains more fully the definition or examples of the term in use.

8 Document/s in which the term/definition is used

All terms and definitions should be related to at least one document. If an organisation is not recording standards and products in the SKMT, a single document called ‘organisation glossary’ should be created to which all terms used in the glossaries of that organisation can be referenced. This supports the creation of an extract glossary for that organisation.

9 Category

Indicates the status of the definition:

P – Pending – current work occurring on the definition – it is not final

C – Candidate – definition appears in a published standard or product but has not yet been harmonized across all member organisations of the Joint Initiative Council

S – Standard – definition has been harmonised and confirmed as the agreed international standard definition in this context

R – Retired – definition has been replaced by a confirmed/harmonized term. It may still be current in the documents/products which it references but should not be used in new documents, and should be replaced when current documents or products are updated.

Every term must have a status. When entered into the system users may only indicate that a term is a candidate or a pending term. The glossary administrator is responsible for recording that a term is to be considered a standard or has been retired

10 Version

Number indicating the sequence of the version of the definition. The highest number is the most recent. This number is automatically generated by the SKMT glossary.

11 Version Date

The date upon which the version of the definition changed. This data is updated automatically.

12 Rationale for change

Where the category, content or structure of the definition and its associated metadata including comments are changed, the reason for the change must be documented. This supports improved understanding of the logic behind any change and reduces later circular arguments for change.

Process for usage

Each organisation is responsible for establishing their own process for inclusion of material and handling of harmonisation requests for the glossary.

Each organisation should determine the person or people responsible for maintaining the glossary entries within their organisation. Access is granted to read all entries, but to update only those entries from your organisation. The exception to this is the Administrator who, due to the need for harmonisation across organisations, is able to update any definitions in the system, though this does not include deletion, nor the removal of the link to relevant documents.

Figure 1 indicates the process for creating or updating the terms and definitions sections of documents or products or organisational glossaries.

[pic]

Figure 1 Process for glossary creation and update

Initial use of the SKMT Glossary has identified significant savings of volunteer time when this process is used. As the need for harmonisation reduces over time, the process will be come even more efficient

Each organisation must determine how it will handle

• the requests for harmonisation prepared by other SDO’s

• the requirement to update the SKMT (preferably before publication)

• The requirement to check the SKMT for definitions BEFORE new definitions are developed

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