Iso tc tc 215/sc n339 Date: August 2003 iso/pdts



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ISO TC TC 215/SC N339

Date: August 2003
ISO/PDTS

ISO TC TC 215/SC /WG 1 Secretariat: ANSI
Health informatics — Health indicators definitions, relationships and attributes

Warning

This document is not an ISO International Standard. It is distributed for review and comment. It is subject to change without notice and may not be referred to as an International Standard.

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Document type: Technical Specification Document subtype: Document stage: (20) Preparatory Document language: E
Copyright notice

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Contents

Contents ..................................................................................................................................................................iii


1 Scope ...........................................................................................................................................................1


2 Normative references .................................................................................................................................1


3 Terms and definitions.................................................................................................................................2


4 Health indicators conceptual framework with associated attributes......................................................6


4.1 Framework...................................................................................................................................................6


5 Health Status ...............................................................................................................................................9


5.1 Health status dimension description.........................................................................................................9


6 Non-medical determinants of health .......................................................................................................10


6.1 Non-medical determinants of health dimension description.................................................................10


7 Health System Performance.....................................................................................................................11


7.1 Health system performance dimension description ..............................................................................11


8 Community and health system characteristics ......................................................................................12


8.1 Community and health system characteristics dimension description ...............................................12


9. Dimension relationships ..................................................................................................................................13


9.1 General .............................................................................................................................................................13


9.2 Relationships ...................................................................................................................................................14


9.2.1 Relationships – General ...............................................................................................................................14


9.2.2 Relationships – Health status ......................................................................................................................15


9.2.3 Relationships – Non-medical determinants of health ................................................................................15


9.2.4 Relationships – Health system performance..............................................................................................16


9.2.5 Relationships – Community and health system characteristics ...............................................................18


10. Attributes ...................................................................................................................................................19


10.1 General ......................................................................................................................................................19


10.2 Attribute visibility and type ......................................................................................................................19


10.2.1 Visibility of an attribute .............................................................................................................................19


10.2.2 Type of an attribute....................................................................................................................................19


10.3 Health indicator class attributes and definitions....................................................................................19


10.3.1 Health status dimension...........................................................................................................................19


10.3.2 Non-medical determinants of health dimension.....................................................................................21


10.3.3 Health system performance dimension ..................................................................................................24


10.3.4 Community and health system characteristics dimension....................................................................28


Annex A ..................................................................................................................................................................30


Annex B ..................................................................................................................................................................31


Bibliography...........................................................................................................................................................33


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 3.

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 other circumstances, particularly when there is an urgent market requirement for such documents, a technical committee may decide to publish other types of normative document:

  1. an ISO Publicly Available Specification (ISO/PAS) represents an agreement between technical experts in an ISO working group and is accepted for publication if it is approved by more than 50 % of the members of the parent committee casting a vote;

  2. an ISO Technical Specification (ISO/TS) represents an agreement between the members of a technical committee and is accepted for publication if it is approved by 2/3 of the members of the committee casting a vote.


An ISO/PAS or ISO/TS is reviewed every three years with a view to deciding whether it can be transformed into an International Standard.

ISO/PDTS [ISO designation yet to be assigned] Health indicators definitions, relationships and attributes, was prepared by Technical Committee ISO/TC 215, Health Informatics / Working Group 1 Health records and modelling coordination.
Introduction

Heightened interest in the measurement and monitoring of the performance of health care systems, as well as accountability and responsiveness to payors and stakeholders, is now evident on an international scale. Consequently, many countries have begun the systematic definition and collection of health information for monitoring health system performance. This trend is concomitantly driven, and driven by, an enhanced data infrastructure that allows for more explicit and rigorous examination of both the health of populations and their health care systems. More often than not, this has taken the form of the collection of specific health indicators with which to describe a variety of health and health system-related trends and factors.

The term health indicator refers to a single summary measure, most often expressed in quantitative terms, that represents a key dimension of health status, the health care system or related factors. A health indicator must be informative, and also be sensitive to variations over time and across jurisdictions.

In order for a health indicator to be useful for monitoring health or health system performance, however, explicit criteria must be applied for its choice and definition. The selection should be based on some agreement about what is to be measured and for what purpose, and informed by a clear conceptual framework. This implies a common framework, to be used internationally, for structuring the way health and health system performance is measured.

This technical specification describes a comprehensive, high-level taxonomy of the key types of indicators that are useful for assessing population health and health services. It identifies the relationships and attributes important in defining these health indicators. From the perspective of electronic systems a formal representation of these indicators is an important step toward operationalizing the implementation of these indicators. Additionally, these definitions will help to improve the consistency with which the indicators are applied and, most directly, the interoperability between implementations. Although the syntax is not directly specified, one can easily imagine an XML representation of the health indicators.

Using ISO/TS 21667 Health informatics - Health indicators conceptual framework along with the formal definitions and attributes specified in this specification will undoubtedly foster a common language for communication between countries, and ultimately, lead to greater commonalities for indicator development. This could, and in fact should, lead to greater potential for generating internationally comparable health data in the long term, in order to permit consistent reporting, dissemination and analysis.

In order for these health indicators to be useful in electronic systems, they must be defined formally as well as systematically. This requires a set of attributes for each indicator and a set of semantics linking the indicators into an ontology of health indicators. This creation of a high-level ontological representation is essential for the consistent use of these indicators in electronic environments and reporting systems. Furthermore, to begin to aggregate this data from detailed underlying coded clinical representations (eg using a nomenclature which uses a compositional system for the representation of detailed clinical data such as Galen or SNOMED-CT®) will require computable formal definitions for these indicators.

These definitions are crafted to provide aggregation across a continuum of specificity with regard to health data. For instance, one might want to aggregate data for these indicators from data encoded in an administrative classification eg ICD10 (Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems) which in turn may have been aggregated from data encoded using a detailed nomenclature. This ‘record-once-and-use-many-times’ philosophy, ie repurposing of data, is one of the important goals of computerizing health information.
Health informatics — Health indicators definitions, relationships and attributes

1 Scope

This technical specification establishes definitions for a set of common health indicators, and is intended to specify a common vocabulary, a common set of semantics and conceptual definitions for ISO/TS 21667.

2 Normative references

The following normative documents contain provisions that, through reference in this text, constitute provisions of this Technical Specification. For dated references, subsequent amendments to, or revisions of, any of these publications do not apply. However, parties to agreements based on this Technical Specification are encouraged to investigate the possibility of applying the most recent editions of the normative documents indicated below. For undated references, the latest edition of the normative document referred to applies. Members of ISO and IEC maintain registers of currently valid International Standards.

ISO 704 Terminology work - Principles and methods ISO/DIS 860 Terminology work - Harmonization of concepts and terms ISO 1087-1 Terminology work – Vocabulary – Part 1: Theory and application ISO 1087-2 Terminology work – Vocabulary – Part 2: Computer applications ISO 11179-3 Information technology – Specification and standardization of data elements – Basic attributes

of data elements ISO 12200 Computer applications in terminology – Machine-readable terminology interchange format

(MARTIF) – Negotiated interchange ISO 12620 Computer applications in terminology – Data categories ISO TS 21667 Health informatics – Health indicators conceptual framework ISO/IEC 2382-4 Information technology – Vocabulary – Part 4: Organization of data ISO/IEC/TR 9789 Information technology – Guidelines for the organization and representation of data elements for

data interchange – Coding methods and principles ISO TS 17117 Health Informatics — Controlled health vocabularies — vocabulary structure and high-level indicators E-1238 Standard Specification for Transferring Clinical Observations Between Independent Computer Systems E-1239 Standard Guide for Description of Reservation / Registration – Admitting, Discharge, Transfer (R-ADT) Systems for Electronic Health Record (EHR) Systems E-1284 Standard Guide for Construction of a Clinical Nomenclature for Support of Electronic Health

Records E-1384 Standard Guide for Content and Structure of the Electronic Health Record (EHR) E-1633 Standard Specification for Coded Values Used in the Electronic Health Record E-1712 Standard Specification for Representing Clinical Laboratory Test and Analyte Names ENV 12017 Health Informatics - Medical Informatics Vocabulary ENV 12264 Health Informatics - Categorical Structures of Systems of Concepts – Model for Representation

of Semantics



3 Terms and definitions

For the purposes of this Technical Specification, the following terms and definitions apply.

3.1 health indicators conceptual framework

A framework that:

a) defines the appropriate dimensions and sub-dimensions that are required to describe the health of the population, and the performance of a health care system;

b) is sufficiently broad (high-level) to accommodate a variety of health care systems; and

c) is comprehensive and, as such encapsulates all of the factors that are related to health outcomes, health system performance and utilization, and regional and national variations

NOTE See Annex C of ISO TS 21667 for a more complete discussion of the underlying rationale for this framework.



3.2 terminology

a set of terms representing a system of concepts within a specified domain

NOTE This implies a published purpose and scope from which one can determine the degree to which this representation adequately covers the domain specified.



3.3 controlled health vocabulary

terminology intended for clinical use

NOTE This implies enough content and structure to provide a representation capable of encoding comparable data at a granularity consistent with that generated by the practice within the domain being represented as well as within the purpose and scope of the terminology.



3.4 classification

a terminology that aggregates data at a prescribed level of abstraction for a particular domain

NOTE This establishment 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. An illustration of this activity is the use of the system with some of the current billing classification schemes.



3.5 ontology

an organization of concepts for which one can make a rational argument

NOTE Colloquially, this term is used to describe a hierarchy constructed for a specific purpose.

EXAMPLE A hierarchy of qualifiers would be a qualifier ontology.



3.6 qualifier

a string, which when added to a term, changes the meaning of the term in a temporal or administrative sense

EXAMPLE ‘History of’ or ‘recurrent’.



3.7 modifier

a string, which when added to a term, changes the meaning of the term in the clinical sense

EXAMPLE ‘clinical stage’ or ‘severity of illness’.



3.8 canonical term

a preferred atomic or pre-coordinated term for a particular medical concept



3.9 term

a word or words corresponding to one or more concepts



3.10 reference terminologies

the set of canonical concepts, their structure, relationships and, if present, their systematic and formal definitions

NOTE These features define the core of the controlled health terminology.





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