A Hitchhikers Guide to Electronic Health Record Vocabulary

for

Health Information Professional Specialties

Version 1.0

1 October 2000

Arden W. Forrey

University of Washington

Introduction

This Guide is intended for the health professional specialist and informatician. It is organized to help introduce and understand the myriad interlocking concepts that characterize the Electronic Health Record, its place in the Electronic Health Information Domain (see References 1-5) and its impacts on Healthcare. It is, therefore, also intended to be a pocket resource for use during the various educational forums that will be organized and published in order for the Health Information professional specialty disciplines to quickly attain mastery of the basic concepts.

The Guide is organized in two sections: Acronyms and Terms. Acronyms appear ubiquitously in speech and print as “short-talk” for concepts with long names. This section is designed to remind the reader of the associated concepts. The Term section gives a definition, if the reader is unfamiliar with the words comprising the acronym or the implications of the complete term. The definitions refer to terms for healthcare informatics collected for an ASTM Guide on this subject by Subcommittee E-31.01 on Controlled Health Vocabularies for Health Information which contains terms applying across healthcare that are not generic to Information and Communication Technology (ICT). Terminology related to general information systems appears in References 6-9.Terminology relating generally to healthcare information appears in CEN EN 12264 and EN 12017 and in UMLS. The terms used frequently from these sources appear here, in addition to those terms specific to this Guide.

This abstracted vocabulary has been prepared by the University of Washington School of Dentistry Department of Oral Medicine Division of Information Technology and Research with the help of ASTM Technical Subcommittee E-31.01 and its parent Technical Committee E-31 on Health Informatics. and it is being made available to promote consistency in the dialog regarding the Electronic Health Record. It will be updated at regular intervals in order to reflect the current status of vocabulary usage about the EHR.

References

1. Forrey, A AACC TDM/TOX LIP Therapeutic drug Monitoring and Toxicology 20 No 5 February 1999 p 33-53

2. Kolodner R Computerizing Large Integrated Health Networks: The VA Experience Springer 1998

3. Murphy G, Hanken MA, Waters K: Electronic Health Records: Changing the Vision Saunders 1999

4. Van Bemel JH, Musen MA: Medical Informatics Springer 1997

5. Dick RS, Steen EB, Detmer D: The Computer-based patient record: An Essential technology for Healthcare 1991, revised 1997 National Academy Press Washington DC

6. Rigg JC, Brown SS, Dybkaer R, Olesen H: Compendium of Terminology and Nomenclature of Properties in Clinical Laboratory Science (IUPAC Silver Book) Blackwell Science Oxford UK 1995

7. X3.172 American National Dictionary for Information Systems

8. IEEE:

610.2 Computer Applications

610.3 Modeling and Simulation

610.4 Image Processing and Pattern recognition

610.5 Data Management

610.6 Computer Graphics

610.7 Computer Networks

610.10 Computer Hardware

610.12 Software Engineering

610.13 Computer Languages

729 Fundamental Terms of Software Engineering

Sources

1. CEN PrENV 1994

2. CEN EN 12017

3. CEN Global Glossary

4. AHIMA Glossary

5. Andover Working Group Glossary

6. DoD Glossary

7. ASTM E-1384

8 ASTM E-1239

9. ASTM E-1869

10. Institute of Medicine 1991 rev 1997

11. International Vocabulary of Metrology (VIM)

12. IS 1087 Terminology - Vocabulary - Theory and Application

13. IS 2382-4 Information Processing Systems -Vocabulary

14. IEEE 610.12 Glossary of Software Engineering

Acronyms

AHIMA American Health Information Management Association

ANSI American National Standards Institute

ASTM American Society for Testing and Materials

CAP College of American Pathologists

CDC Centers for Disease Control and Prevention, Dept. of Health and Human Services

CDSS Clinical Decision Support Systems

CEN Commission European Normalization (standardization)

CLIMS Clinical Laboratory Information Management System

CPR Computer-based Patient Record (see EHR)

CPRI Computer-based Patient Record Institute

DHHS Department of Health and Human Services

DoD/DOD Department of Defense

EHR Electronic Health Record

EMR Electronic Medical Record (see EHR)

EPR Electronic Patient record (see EHR)

GUM Guide to Uncertainty in Measurement

HIN Health Information Network

HISB Health Informatics Standards Board

HISPP Health Informatics Standards Planning Panel

HL7 Health Level 7

ICD Intermittently Connected Device; also International Classification of Diseases

ICT Information and Communication Technology

IDS Integrated Delivery Systems

IEC International Electrotechnical Commission

IEEE Institute of Electrical and Electronic Engineers

JTC1 Joint Technical Committee 1

ISA Information Systems Architecture

LAS Laboratory Automation System

LIMS Laboratory Information Management System

MDSS Management Decision Support System

MCO Managed Care Organization

MLM Medical Logic Module

MPI Master Person/Patient Index

NCVHS National Committee on Vital and Health Statistics

NPF National Provider File

NPI National Provider Identifier

NPS National Provider System

OMB Office of Management and Budget

OTA Office of Technology Assessment

POC Point-of-Care

POCT Point-of-Care Testing

PPO Preferred Provider Organization

RADT Registration, Admitting, Discharge and Transfer

SDO Standards Developer Organization

SSAN Social Security Account Number (also SSN)

TC Technical Committee

TDM Therapeutic Drug Monitoring

TOX Toxicology

UCT Universal Coordinated Time

UMLS Unified Medical Language System

UPI Universal Patient Identifier

VA Dept. of Veterans Affairs

VIM International Vocabulary of Measurement

Terms

ACCESS

1) Possibility to retrieve medical information stored in a database or remote application. Access should be limited by security authentication mechanisms. 2) the provision of an opportunity to approach, inspect, review, retrieve, store, communicate with or make use of health information system resources (for example, hardware, software, systems or structure) or patient identifiable data and information, or both (ASTM E-1869).

Source 3

ACCESS CONTROL

Prevention of use of a resource by unidentified and/or unauthorized entities. Note: adapted from CEN/TC-251 directory

Source 2

ADMISSION

1) Formal acceptance by a hospital of a patient who is to be provided with room, board and continuous nursing services in an area of the hospital where patients stay overnight. [ASTM E-1239]

2) initiation of a single patient encounter or visit. Note: an admission has the following potential characteristics: a) assignment of a unique identifier b) relation to a specific encounter type( provision of healthcare services to an inpatient) c) representation of a unit of administrative, accounting, financial and/or statistical significance. d) accordance to business rules e) relation to point of entry f) being based on a physician's order g) relation to specific medical problem h) relation to engagement of specific health care services i) assignment of a fixed location at the time of admission (e.g. examination room, inpatient room/bed) . adapted from ANSI HISPP comments on CEN TC 251/93-147 MIVoc]

Source 2

ADMITTING DIAGNOSIS

Statement of the provisional condition given as the basis for admission to the hospital for study

Source 7

AMBULATORY CARE

Services provided to patients who are neither hospitalized nor institutionalized as INPATIENTS in a healthcare facility which is the site of the encounter

Source 7

ANALYTIC FORM

Structured representation of a composite concept as a composition of concepts using semantic links [PT003(1993)] Source 2

ARDEN SYNTAX

A syntax designed to facilitate the sharing of medical knowledge bases. In its present form the focus is on knowledge that can be represented as a set of independent modules that can provide therapeutic suggestions, alerts, diagnosis scores, etc. Each module is called a Medical Logic Module (MLM) which is made up of slots grouped into maintenance, library, and knowledge categories. [from Hripcsak etal 1990]. The syntax has provisions for querying clincal databases and representing time. The syntax is based largely on HELP and Regenstrief Medical Record systems. The Arden Syntax is named after the Arden Homestead in Harriman, NY State, where a meeting was held to address the sharing of medical knowledge.

Source 3

AUDIT LOG

Record of actions (e.g. additions, deletions, changes, queries) performed on data.

Source 9

AUDIT TRAIL

1) Record of the resources which were accessed and/or used by whom Note 1: this may involve a formal monitoring technique for comparison between the actual use of a medical information system and pre-established criteria.

2) Documentary evidence of monitoring each operation of individuals on health information. (National Research Council 1991) Audit trails may be comprehensive or specific to the individual and information. For example, an audit trail may be a record of all actions taken by anyone on a particularly sensitive file. (OTA 1993)

Source 2

AUTHENTICATE

To denote authorship of an entry made in a patient's medical or dental record by means of a written signature, identifiable initials, a computer key, or a Personally used rubber stamp; also refers to the process of certifying copies as genuine.

Source 6

AUTHENTICATION

Method to establish security services by means of simple or strong authentication. There are two kinds of authentication: data origin authentication and peer entity authentication. the provision of assurance of the claimed identity of an entity, receiver or object. (ASTM E-1869, E-1762, CPRI)

Source 3

BASE CONCEPT

Concept without characteristics.

Source 2

BED CENSUS

Statistic of bed usage in a hospital at a given time.

Source 2

CALIBRATION

Set of operations which establish, under specified conditions, the relationship between values indicated by a measuring instrument or measuring system, or values represented by a material measure or reference material, and the corresponding values of a quantity realized by a reference standard.

Source 3

CENSUS

Statistic of bed usage in a hospital at a given time.

Source 2

CERTIFICATION

Process by which governmental or non-governmental agency or association evaluates and recognizes a person who meets pre-determined standards; sometimes used with reference to materials and services. "certification" is usually applied to individuals and "accreditation" to institutions.

Source 6

CLINICAL DECISION SUPPORT SYSTEM

Computer system designed to help healthcare professionals make clinical decisions. Note: adapted from Shortliffe.

Source 2

CLINICAL INVESTIGATION

Laboratory, physiological, radiological or other healthcare examination that leads to the production of one or more results.

Source 3

CLINICAL LABORATORY INFORMATION MANAGEMENT SYSTEM

Information system that manages clinical laboratory data to support laboratory management, laboratory data collection and processing, PATIENT care and medical decision making. Note: it may be part of a HOSPITAL INFORMATION SYSTEM, or it may be independent.

Source 2

CLINICAL OBSERVATION

Clinical information excluding information about treatment and intervention.

Source 3

CLINICAL ORDER

Request for a certain procedure to be performed.

Source 2

CODE MEANING

Element within a coded set. [ISO 2382/4]

Source 2

CODE VALUE

Result of applying a coding scheme to a code meaning. [ISO 2382/4]

Source 2

CODING SCHEME

Collection of rules that maps the elements of one set onto the elements of another set. [ISO 2382/4]

Source 2

COMPONENT

Definable part of a system. A "Chunk” of software responsible for performing a set of tasks within a facet of a system's architecture.[Andover Working Group Glossary]

Source 5

COMPONENT CONCEPT

Base concept or specifying concept. PT003(1993)

Source 1

COMPOSITE CONCEPT

Concept with its characteristics. [PT003(1993)]

Source 1

COMPUTER BASED PATIENT RECORD

HEALTH CARE RECORD stored in electronic format Note: this framework representing the main healthcare subsystems, their connections, rules, etc. is the basis for the development of information and communication systems.

Source 10

CONCEPT SYSTEM

Structured set of concepts established according to relations between them, each concept being determined by its position in the set.

Source 2

CONFIDENTIALITY

1) Property that information is not made available or disclosed to unauthorized individuals, entities or processes. [ISO 982]

Note: the prevention of the unauthorized disclosure of information [ISO/IEC 10118-2]

2) Status accorded to data or information indicating that it is sensitive for some reason, and therefore it needs to be protected against theft, disclosure, or improper use, or both, and must be disseminated only to authorized individuals or organizations with approved need to know. (ASTM E-1869) Private information which is entrusted to another with the confidence that unauthorized disclosure which would be prejudicial to the individual will not occur. (CPRI)

Source 2

COST BENEFIT ANALYSIS

Analysis of costs and benefits associated with courses of action that is designed to identify the alternative that yields the maximum net benefit. This method is generally used when it is possible to assign monetary values to all relevant benefits and costs.

Source 3

COST EFFECTIVENES ANALYSIS

Analysis of alternative courses of action, the objective of which is to identify whether the alternative that yields the maximum effectiveness achievable for a given amount of spending, or the alternative that minimizes the cost of achieving a stipulated level of effectiveness. The method is generally used when it is not possible to assign monetary values to benefits.

Source 3

DATA ELEMENT

Combination of one or more data entities that forms a unit or piece of information, such as the Social Security Number, a diagnosis, and address or a medication. (ASTM PS 107)

Source 13

DATA INTEGRITY

Property that information is protected from accidental or malicious alteration.

Source 2

DECISION SUPPORT SYSTEM

Any computer-based support of medical, managerial, administrative and financial decisions in health using knowledge bases and/or reference material. [In this sense the term is essentially synonymous with Knowledge-based Systems, and some users use the term this way in preference the terms Expert System or Knowledge-based System, eg a system that uses statistical lookup to provide users with decision support may be regarded as a Decision Support System, therefore care should be taken in making this identification between the terms].

Source 3

DEMOGRAPHIC INFORMATION

Information concerning population statistics such as birth date, birth place, sex, residence, etc. Collected and used for healthcare evaluation and planning purposes.

Source 3

DESIGN VIEW

Specification of how the Healthcare Enterprise operations are to be performed, that is the actions and processes that are to be performed to achieve the requirements. (Derived from [COMOSA]) [PT010 (1993)]

Source 1

DIGITAL SIGNATURE

Data appended to, or a cryptographic transformation of, a data unit that allows a recipient of the data unit to prove the source and integrity of the data unit and protect against forgery e.g. by the recipient. [from ISO 7498-2]

Source 2

DISEASE

Illness, sickness, and interruption, cessation or disorder of body functions, systems or organs due to an entity characterized usually by at least two of these criteria: a recognized etiologic agent (or agents), an identifiable group of signs and symptoms, or consistent anatomical alterations

Source 8

DISPOSITION

Directing of a patient from one environment/healthcare delivery mode to another at the conclusion of services. ASTM E-1239

Source 8

DOMAIN INFORMATION MODEL

Conceptual model describing common concepts and their relationships for communication parties required to facilitate exchange of information between these parties within a specific domain of healthcare

Source 2

ELECTRONIC PATIENT CARD

Computer readable card used to establish the entitlement of a PATIENT used for some purpose connected to the receipt of healthcare services.

Source 2

ELECTRONIC PATIENT INSURANCE CARD

Computer readable card used to establish the entitlement of a PATIENT to a healthcare service or benefit and/or the identity of the organization responsible for providing or funding that service or benefit.

Source 2

EMERGENCY SERVICES

Immediate evaluation and therapy rendered in emergency clinical conditions, sustained until the patient can be referred to a private practitioner for further care.

Source 7

ENCOUNTER

1) Professional contact between a PATIENT and a provider who delivers services or is professionally responsible for services delivered to a patient: A face-to-face contact between a PATIENT and a provider who has primary responsibility for assessing and treating the PATIENT at a given contact, exercising independent judgement. [AHIMA Glossary of Health Care Terms and also ASTM E-1239]

Source 7

ENROLLMENT

Process by which participation status in a health plan is established.

Source 6

ENTERPRISE

An enterprise is defined as an entire corporation, consisting of one or more organizational components, with the prime objective of producing products or offering services.[PT010(1993)]

Source 2

EPISODE

Period of time during which clinical care is provided for an illness or clinical problem, rendered either in an ambulatory or HOSPITAL INPATIENT setting.

Source 7

EXPERT SYSTM

Program that symbolically encodes concepts derived from experts in the field and uses that knowledge to provide the kind of problem analysis and advice that the expert might provide.

Source 3

GLOSSARY

A list of terms (usually alphabetically sorted) with explanations pertaining to a particular field.

Source 3

HEALTH INFORMATION NETWORK

A set of data domains (nodes) and communications pathways (arcs) serving a healthcare constituency with information management services. <To be cited>

Source

HEALTHCARE CODING SCHEME

Coding scheme used in healthcare. [ENV 1068]

Source 2

HEALTHCARE ENTERPRISE

Enterprise providing healthcare of varying coverage and complexity. E.g. a primary care center, a department within a hospital, a hospital, a regional care service or a national health service. They are heterogeneous, autonomous but integrated units among which the real world of healthcare and health information are distributed. [PT010(1993)]

Source 2

HEALTHCARE ENTERPRISE VIEW

Selective perception of an healthcare enterprise which emphasizes some particular aspect and disregards others.

Source 2

HEALTHCARE INFORMATICS

Scientific discipline that concerns itself with the cognitive, information processing and communication tasks of healthcare practice, education and research, including the information science and technology to support these tasks

Source 2

HEALTHCARE ORGANIZATION

Organization or person responsible for the direct or indirect the provision of healthcare services to a subject, or involved in the provision of healthcare related services such as environmental testing.

Source 2

HEALTHCARE PROCEDURE

Systematic activity directed at or performed on an individual with the object of improving health, treating disease or injury, or making a diagnosis. Some kind of method and systematic application is involved.

Source 3

HEALTHCARE RECORD

Systematic record of the history of a PATIENT kept by a physician or other HEALTHCARE PRACTITIONER. Document which records the provision of health services to an individual patient. Health records include both outpatient treatment and dental care. DoD Glossary of Healthcare terminology (in part). 2) set of information for a single individual's encounter with the healthcare system. It contains data and information generated across care settings and from different healthcare interactions. The set of data may be viewed in various ways, ie, brief summary emergency data. 3) it is the primary legal record documenting the healthcare services provided to an individual. (E-1384) Note: this term is used to refer to medical record, patient care record, clinical record, client record, resident record, electronic medical record and computer-based patient record. The term includes routine clinical or office records, records of care in any health setting, research protocols, preventive care, lifestyle evaluation, special study records and various clinical databases. (E-1384) [ASTM E-1869]

Source 9

HOSPITAL INFORMATION SYSTEM

Integrated, computer-assisted system designed to store manipulate, and retrieve information concerned with the administrative and clinical aspects of providing services within the hospital

Source 2

HUMAN ANATOMY

Organ system, organ, suborgan, bodypart or anatomic region described without reference to the side of the body

Source 2

INTERMITTENTLY CONNECTED DEVICE

Device that is physically moved between different locations and is intermittently connected to one or more devices for the purpose of updating the information held on it and the other devices.

Source 2

IDENTIFIER

A symbol used to name, indicate or locate. Identifiers may be associated with such things as data structures, data items, or program locations. (IEEE 610.12)

Source 14

IMAGE MANAGEMENT AND COMMUNICATION SYSTEM

System that can store, distribute, retrieve and display images.

Source 2

INCIDENCE

Expression of the rate of which a certain event occurs, such as the number of new cases of a specific disease occurring during a certain period.

Source 6

INFORMATICS

Discipline concern with the study of information and its manipulation via computer-based tools.

Source 3

INFORMATION

Organized data or knowledge that provides a basis for decision-making data to which meaning is assigned, according to context and assumed conventions. (national Security Council 1991, ASTM E-1869)

Source 3

INFORMATION MODEL

Semantic model used to ensure a consistent interpretation of data contained in messages in order to avoid and/or clarify ambiguities in message data elements sometimes resulting from different implementations of a standard.

Source 5

INFORMATIONAL PRIVACY

1) State or condition of controlled access to personal information,

2) Ability of the individual to control the use and dissemination of information that relates to himself or herself,

3) Individual's ability to control what information is available to various users and to limit redisclosures of information.

Source 9

INPATIENT

PATIENT who is admitted to a healthcare: facility in order to receive healthcare CEN N93.-143 An individual receiving, in person, resident hospital based or coordinated medical services for which the hospital is responsible: ASTM E-1239. individual, other than a transient patient, who is admitted (placed under treatment or observation) to a bed in a treatment facility which as authorized or designated beds for inpatient medical or dental care. DoD Glossary of Healthcare Terminology

Source 6

INPATIENT ADMISSION

Formal acceptance by a hospital of a patient who is to be provided with room, board, and continuous nursing service in an area of the hospital where patients generally stay overnight

Source 7

INTERMEDIATE CARE

That care rendered to patients whose physiological and psychological status is such that they require observation and nursing care for the presence of real or potential life-threatening disease/injury. The acuity of care may range from those requiring constant observation and care to those patients able to ambulate and begin assuming responsibility for their own care.

Source 6

KEY MANAGEMENT

Generation, storage, distribution, deletion, archiving and application of (cryptographic) keys in accordance with security policy.

Source 2

KIND-OF-PROPERTY

Function taking one or more properties of a system and zero or more properties of components of the system as arguments and returning a property of the system.

Source 2

KIND-OF-QUANTITY

Function taking one or more quantities of a system and zero or more properties of components as arguments and returning a quantity of the system.

Source 2

LABORATORY EXAMINATION

MEDICAL PROCEDURE that consists of performing tests in a laboratory on samples obtained from a PATIENT

Source 2

LABORATORY INVESTIGATION

Clinical laboratory examination that leads to the production of one or more results.

Source 3

LABORATORY SERVICE ORDER

Set of one or more requested investigations submitted to a laboratory service provider, pertaining to one or more specific systems, usually in one individual, and including pertinent specific and general information.

Source 2

LABORATORY SERVICE PROVIDER

Authorized healthcare party qualified to perform laboratory services and to validate the resulting laboratory service report.

Source 2

LABORATORY SERVICE REPORT

Report of results of laboratory investigations of one or more properties pertaining to one or more specified systems, usually in one individual, and including pertinent information extracted from the laboratory service order as well as additional comments, suggestions and advice given by the laboratory service provider.

Source 2

LICENSED PRACTITIONER

Individual at any level of professional specialization who requires a public license/certification to practice the delivery of care to patients. Note: a practitioner can also be a provider.

Source 7

LONGITUDINAL PATIENT RECORD

Records from different times, providers, and sites of care that are linked to form a lifelong view of a patient's healthcare experiences.

Source 10

MAJOR INDUSTRY IDENTIFIER

Code that identifies the sector/industry within which the ICD is used.

Source 2

MEDICAL PROCEDURE

Systematic activity directed at, or performed on an individual PATIENT with the object of improving or restoring health, treating disease or injury, preventing sequels, or making a diagnosis

Source 2

METATHESAURUS

Integration of several different thesauri, to produce a new larger Thesaurus. It includes cross-references between different thesauri from which it is composed.

Source 3

MINIMUM BASIC DATA SET

Set of data that is the minimum required for a HEALTHCARE RECORD to conform to a given standard.

Source 2

MULTIAXIAL CLASSIFICATION

System of concepts with a structure depending on a number of selected characteristics.

Source 2

NARRATIVE SUMMARY

Medical Report dictated prior to a patient's discharge from an inpatient facility and ultimately included in the health record.

Source 6

ORDER ENTRY SYSTEM

System for recording and processing CLINICAL ORDERS .

Source 2

OUTPATIENT

PATIENT who does not reside in a healthcare facility. An individual receiving healthcare services for an actual or potential disease, injury, or lifestyle-related problem that does not require admission to a medical facility for inpatient care. [DOD Glossary of Healthcare Terminology]

Source 8

PARTICULAR PROPERTY

Property of a given object (phenomenon, body or substance).

Source 3

PARTICULAR QUANTITY

Quantity of a given object (phenomenon, body or substance).

Source 3

PATIENT

1) Person who is the target of healthcare activity. Source 2 ; 2) A sick, injured, wounded or other person requiring medical/dental treatment: [DoD Glossary of Healthcare Terminology]

Source 6

PATTERN RECOGNITION

Automatic or semi-automatic signal processing function to recognize definite patterns which can be either normal or abnormal pathology to assist diagnosis.

Source 3

POINT-OF-CARE SYSTEM

HOSPITAL INFORMATION SYSTEM that includes Practitioner, licensed (E-1384): An individual at any level of professional specialization who requires a public license/certification to practice the delivery of care to patients. A practitioner may also be a Provider.

Source 2

PREVALENCE

Total number of cases of a disease in existence at a certain time in a designated area.

Source 6

PRIMARY DIAGNOSIS

Statement of the conditions established after study that are most resource intensive.

Source 7

PRIMARY RECORD OF CARE

Primary legal record documenting the health services provided to a person, in any aspect of healthcare delivery. This term is synonymous with: medical record, health record, patient care record. This is the original record of care delivered to a patient and is the data source for all synoptic records, such as the longitudinal summary patient record. The term includes routine clinical or office records, research protocol, special study records and various clinical databases.

Source 7

PRINCIPAL PROCEDURE

Procedure which has therapeutic rather than diagnostic, most related to the principal diagnosis, or necessary to take care of a complication.

Source 6

PRIVACY

Right of individuals to control or influence what information related to them may be collected and stored and by whom and to whom that information may be disclosed.

Source 3

PROBLEM DOMAIN

Field under consideration in the modeling process.

Source 2

PROBLEM-ORIENTED MEDICAL RECORD

HEALTHCARE RECORD in which all data may be linked to a list of health problems of an individual PATIENT cf: TIME-ORIENTED MEDICAL RECORD.

Source 2

PROTOCOL

Written procedure providing basic guidlines for management (diagnosis and treatment) of specific types of medical or dental patient care in specified circumstances.

Source 6

PROVIDER

Business entity which furnishes healthcare to a consumer. It includes a professionally licensed

practitioner who is authorized to operate a healthcare delivery facility. (E-1384)

Source 7

QUANTITY (MEASUREABLE OR PHYSICAL)

(in a general sense): Attribute of a phenomenon, body or substance that may be distinguished qualitatively and determined quantitatively.

Source 11

REFERENCE MODEL

A structure used to describe a logical process.

Source 3

REFERRAL SYSTEM

Patient booking system for requests for examination and treatment.

Source 2

REGISTRATION AUTHORITY (FOR HEALTHCARE CODING SCHEMES)

Body responsible for assigning healthcare coding scheme designators and for maintaining the register of healthcare coding schemes as described in ENV 1068. [ENV 1086]

Source 2

REGISTRY

Archive for the systematic and continuous followup of PATIENTS of a certain disease category.

Source 2

REQUESTED INVESTIGATION

Request for a single (laboratory) service to be carried out with respect to a specified subject of investigation.

Source 2

RISK MANAGEMENT

Identification of risk exposures, the evaluation of risks identified, and the elimination or reduction of risk to an acceptable minimum.

Source 2

SECONDARY DIAGNOSIS

Statement of those conditions co-existing during the episode that affect the treatment received or the length of stay.

Source 7

SECURITY

Controls of threats made to the integrity of a system.

Source 3

SEMANTIC LINK

Relation from a concept to a specifying concept.

Source 2

SEMANTICS

Meaning of symbols and codes.

Source 3

SERIOUSLY ILL

Patient is seriously ill when his illness is of such severity that there is cause for immediate concern but there is no imminent danger to life.

Source 6

SERVICES

Acts performed by certain persons on behalf of other persons.

Source 4

SPECIFYING CONCEPT

Concept used in a characteristic SPECIMEN.

Source 2

SPONSORING AUTHORITY (FOR HEALTHCARE CODING SCHEMES)

Body recognized by the requirements of ENV 1068 to receive requests for registration of healthcare coding schemes from issuing organizations and submitting them to the Registration Authority. [ENV 1068]

Source 2

STRUCTURE (OF A CONCEPT SYSTEM)

Concept system containing the top base concepts, the top specifying concepts and their relations only.

Source 2

SUBJECT OF (LABORATORY) INVESTIGATION

Person, animal or material subject to investigation.

Source 2

SUBORDINATE CONCEPT

Concept in a hierarchical system which can be grouped together with at least one more concept of the same level to form a higher ranking concept. [ISO 1087:1990]

Source 2

SUPERORDINATE CONCEPT

Concept in a hierarchical system which can be subdivided into a number of lower ranking concepts. [ISO 1087]

Source 2

SYNTAX

Rules to present and transfer symbols and codes.

Source 3

TERMINOLOGY

Collection of terms used in a particular discipline.

Source 3

THERAPEUTIC PROCEDURE

Procedure used for therapeutic purposes; i.e. A procedure used to cure, alleviate or improve a medical problem.

Source 3

TIME-ORIENTED MEDICAL RECORD

HEALTHCARE RECORD in which data appear in chronological sequence.

Source 2

TYPE OF CHARACTERISTIC

Any category of characteristics used as a criterion for the establishment of a generic system of concepts. [ISO 1087]

Source 2

TYPE OR VALUE REFERENCE NAME

Name associated uniquely with a type or value within some context. [ISO 8824]

Source 2

UNIT OF MEASUREMENT

Particular quantity, defined and adopted by convention, with which other quantities of the same kind are compared in order to express their magnitudes relative to that quantity. [VIM]

Source 2

VALUE OF A QUANTITY

Magnitude of a particular quantity generally expressed as a unit of measurement multiplied by a number. [VIM]

Source 2

VALUE OF A PROPERTY

Element of a scale in relation to which a property is observed or measured.

Source 2

VERY SERIOUSLY ILL

When illness is of such severity that life is imminently endangered.

Source 6

VOCABULARY

Set of terms used for a particular purpose.

Source 3