ASTM Committee E-31.12 on Computer Based Patient Records' standard E 1384-90 on the structure and content of the primary record of care contains data element names which currently reflect the common names used in the clinical setting. In order to be much more explicit and to state definitions that provide a clear statement of the meaning of each data element contained in a database, the assignment of standardized data element names has been undertaken jointly by ASTM E 31.12 and the Defense Medical Data Administration Program that will provide the basis for a national unified catalog of healthcare data elements. The full range of data element associated attributes will be eventually contained in a publicly accessible reference database for use by those organizations or individuals who either build systems or design health care studies so that the data used are standard. The database will also contain derived data elements relating to health care resource management that are consistent with E 1384-90. The data element attributes will be the same as those used in E 1238-91 and E 1239-90.
The structure of each name, using general conventions now being documented for all database systems, will contain three mandatory segments and an optional leading modifier segment. All segments use Reserved Words in fixed positions. The Functional segment and the Categoric segment both begin with a Function Word and Prime Word, respectively, while the Generic segment ends with a Class word. These controlled words will be amplified by a series of qualifiers and modifiers in each segment. Following agreement on a standardized data element contained in the patient care record noted in E 1384-90, the common names will be reviewed for consistency with both the standardized name and the definition. Other attributes of the data element will then be assigned. Any controlled lexicons of data values for these elements will also be identified, such as: diagnosis, procedure, or physical finding. Further work for defining how these lexicons relate to a standardized biomedical terminology is being worked on by ASTM technical committees.
An established ASTM formal Field Test will exercise the use of the standardized names by actual systems and Validate the data within the current database against current manual record practice and public domain automated systems within the Department of Veterans Affairs and the Department of Defense (DoD). Validation against other health care data sets, such as the Uniform Hospital Discharge Dataset, the Uniform Ambulatory Care Dataset, the UB-82 Dataset, and the Uniform Clinical Dataset, is being conducted.