ISO 21667:2010

INTERNATIONAL ISO
STANDARD 21667
First edition
2010-12-01
Health informatics — Health indicators
conceptual framework
Informatique de santé — Cadre conceptuel d'indicateurs de santé

Reference number
©
ISO 2010
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ii © ISO 2010 – All rights reserved

Contents Page
Foreword .iv
Introduction.v
1 Scope.1
2 Terms and definitions .1
3 Health indicators conceptual framework.2
Annex A (informative) Correspondence with OECD health indicator initiatives.7
Annex B (informative) Rationale for a common health indicators conceptual framework .9
Annex C (informative) Background on the health indicators conceptual framework.10
Annex D (informative) Health status .12
Annex E (informative) Determinants of health.13
Annex F (informative) Health system performance.14
Annex G (informative) Community and health system characteristics (contextual indicators).15
Annex H (informative) Equity.16
Bibliography.17

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
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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.
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 21667 was prepared by Technical Committee ISO/TC 215, Health informatics.
This first edition of ISO 21667 cancels and replaces ISO/TS 21667:2004, of which it constitutes a technical
revision.
iv © ISO 2010 – All rights reserved

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 has also concomitantly driven, and is driven by, an
enhanced data infrastructure that allows for more explicit and rigorous examination of 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 must be sensitive to variations over time and across jurisdictions. Indicators are
able to flag issues that require more in-depth examination to determine causes for variation, and to identify
opportunities for improvement, as well as establishing the most effective use of research resources. They may
also be used as a rapid means to evaluate the effects of interventions or to make comparisons as health
systems evolve.
In order for them to be useful for monitoring health or health system performance, however, explicit criteria
must be applied to choosing and defining health indicators. This framework is intended to inform the selection
of health indicators that can be used to monitor and manage the health care system and overall performance
improvements. The selection must be based on some agreement about what is to be measured, and for what
purpose, and be 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 International
Standard describes a comprehensive, high-level taxonomy of the key types of indicators that are useful for
assessing population health and health services. While, in many cases, health indicators may be best
constructed from readily available data, in other situations a health indicators conceptual framework may
inform additional data collection initiatives that are required for understanding health and health system
performance. It is important to note that any data collection must be carried out according to privacy and
confidentiality legislation and ethical principles.
Working toward a standard health indicators framework will undoubtedly foster a common language for
communication between countries and ultimately lead to greater commonalities for indicator development.
This ought to lead to greater potential for generating internationally comparable health data in the long term,
and so permit consistent reporting, dissemination and analysis.
This initiative can also be seen as complementary to work currently underway in other organizations, such as
the Organization for Economic Cooperation and Development (OECD). The adoption of a common health
indicators conceptual framework will further stimulate efforts to develop and collect common health indicators
internationally. Furthermore, a harmonized effort to develop an internationally accepted health indicators
conceptual framework will not only foster increasingly robust cross-national comparisons and analyses, but
may also facilitate the development of comparable data that can be used as a basis for the setting of
international benchmarks. The results of such endeavours may be invaluable for informing national health
policy related to health expenditures, health human resources requirements or the organization of health and
social systems. Ultimately, these developments may facilitate an improved global understanding about
variations in health, variations in health care and the effect of other determinants of health in the context of
other essential factors. Furthermore, indicator collection, benchmarking and analysis can lead to continuous
quality improvement, the identification of factors requiring further analysis and, ultimately, improvements in
health within countries and internationally.
NOTE See Annex A for more information regarding the OECD initiative and its relationship to this International
Standard's health indicators conceptual framework.

INTERNATIONAL STANDARD ISO 21667:2010(E)

Health informatics — Health indicators conceptual framework
1 Scope
This International Standard establishes a common health indicators conceptual framework and is intended to
foster a common vocabulary and conceptual definitions for the resultant framework. The framework
a) defines the appropriate dimensions and sub-dimensions required to describe the health of the population
and performance of a health care system,
b) is sufficiently broad (high-level) to accommodate a variety of health care systems, and
c) is comprehensive, encapsulating all of the factors related to health outcomes and health system
performance and utilization, as well as regional and national variations.
NOTE 1 See Annex B for a more complete discussion of the underlying rationale for this framework.
NOTE 2 Many countries have already developed their own models for directing the collection and analysis of health
indicators. For the purposes of national reporting, these existing frameworks are not expected to change. Rather, this
framework can be viewed as a complement to currently existing frameworks. For example, if a particular health indicators
framework currently focuses only on health system performance, the comprehensive approach proposed here can serve
to augment and/or supplement the currently used model or models.
NOTE 3 Individual jurisdictions may elect to operationalize the conceptual framework differently. Because the
conceptual dimensions represent a high-level taxonomy, this provides considerable discretion and leeway in the selection
of specific indicators by individual countries. This focus on a high-level taxonomy also allows for sufficient flexibility for the
inclusion of new indicators in the future, as new issues emerge and additional data become available. Because specific
data elements are not defined, jurisdictions have the freedom to populate this framework with the most relevant, and
available, indicators for their specific situations.
This International Standard does not identify or describe individual indicators or specific data elements for the
health indicators conceptual framework; nor does it address needs analysis, demand analysis or the range of
activities that need to be supported for health system management.
The definition of benchmarks and/or approaches used in the definition of benchmarks is outside the scope of
this International Standard.
2 Terms and definitions
For the purposes of this document, the following terms and definitions apply.
2.1
health
resource for everyday life, not the objective of living, and a positive concept emphasizing social and personal
resources, as well as physical capacities
[Ottawa Charter for Health Promotion, World Health Organization (WHO), 1986]

2.2
health indicator
single summary measure, most often expressed in quantitative terms, that represents a key dimension of
health status, the health care system, or related factors
NOTE A health indicator must be informative, and also be sensitive to variations over time and across jurisdictions.
3 Health indicators conceptual framework
3.1 Framework
The health indicators conceptual framework shall be as outlined in Table 1. See Annex C for background
information relating to the framework outlined in Table 1.
Table 1 — Health indicators conceptual framework
Dimensions Sub-dimensions
Health status Well-being Health conditions Human function Deaths
Determinants Socio-economic Social and Environmental Genetic
Health behaviours
of health factors community factors factors factors
Health system Acceptability Accessibility Appropriateness Competence
performance
Continuity Effectiveness Efficiency Safety
Community and Resources Population Health system
health system characteristics
characteristics
3.2 Framework dimensions
3.2.1 Health status
The dimension of health status is described in Table 2. See Annex D for further information.
2 © ISO 2010 – All rights reserved

Table 2 — Health status dimension
Sub-dimensions Description Examples of indicators
Well-being Broad measures of the physical, mental and social — Self-rated health
well-being
— Self-esteem
Health conditions Alterations or attributes of health status which may Prevalence of:
lead to distress, interference with daily activities, or
— arthritis
contact with health services; it may be a disease
(acute or chronic), disorder, injury or trauma, or
— diabetes
reflect other health-related states such as
— chronic pain
pregnancy, ageing, stress, congenital anomaly, or
[50]
genetic predisposition
— depression
— food and waterborne diseases
— injury hospitalization
Human function Levels of human function are associated with the — Functional health
consequences of disease, disorder, injury and other
— Disability days
health conditions; they include body
function/structure (impairments), activities (activity
— Activity limitation
limitations and participation (restrictions in
— Health expectancy
[50]
participation)
— Disability-free life expectancy
Deaths A range of age-specific and condition-specific — Infant mortality
mortality rates, as well as derived indicators
— Life expectancy
— Potential years of life lost
— Circulatory deaths
— Unintentional injury deaths
3.2.2 Determinants of health
The dimension of determinants of health is described in Table 3. See Annex E for further information.
NOTE 1 In order to better understand geographic or temporal variations in health status and health system
performance, a variety of determinants of health have been included in the framework.
NOTE 2 Determinants of health are those that fall outside the sphere of medical/health care, generally speaking, but
that have been shown to affect health status and, in some cases, access to health care services.
Table 3 — Determinants of health dimension
Sub-dimensions Description Examples of indicators
Health behaviours Aspects of personal behaviour, and risk — Smoking rate
factors and protective factors that
— Physical activity
epidemiological studies have shown to
influence health status
Socio-economic factors Indicators related to the socio-economic — Unemployment rate
characteristics of the population that
— Low-income rate
epidemiological studies have shown to be
related to health
— High-school graduation
Social and community factors Measures the prevalence of social and
— School readiness
community factors, such as social support,
— Social support
life stress or social capital, that
epidemiological studies have shown to be
— Housing affordability
related to health
— Literacy
Environmental factors Environmental factors with the potential to — Water quality
influence human health
Genetic factors Factors outside those normally influenced — Rates of genetically determined
by individual behaviours or by the social, diseases (e.g. Down's
economic or physical environment; syndrome)
genetic factors determine predisposition to
certain conditions
3.2.3 Health system performance
The dimension of health system performance is described in Table 4. See Annex F for further information.
4 © ISO 2010 – All rights reserved

Table 4 — Health system performance dimension
Sub-dimensions Description Examples of indicators
Acceptability All care/services provided meets the — Patient satisfaction
expectations of the client, community,
providers and paying organizations,
recognizing that there may be conflicting,
competing interests between
stakeholders, and that the needs of the
[6]
clients/patients are paramount
Accessibility The ability of clients/patients to obtain — Surgical waiting times
care/service at the right place and the
— Availability of physicians
[6]
right time, based on respective needs
— Availability of dentists
— Time to appointment
Appropriateness Care/service provided is relevant to the — Inappropriately used surgery
clients'/patients' needs and based on
— Appropriate use of ACE inhibitors at
[6]
established standards
discharge for heart failure
Competence An individual's knowledge and skills are — Proportion of physicians adhering to
appropriate to the care/service being accepted clinical guidelines
[6]
provided
— Proportion of physicians attending regular
continuing medical education
— Medical error due to incorrect practices
Continuity The ability to provide uninterrupted — Patient experiences with duplicate medical
coordinated care/service across tests
programmes, practitioners, organizations,
— Continuity of medication between providers
[6]
and levels of care/service over time
Effectiveness The care/service, intervention or action — Cancer survival
[6]
achieves the desired results
— Recurrence of hernia after repair
— Smoking cessation during pregnancy
(effectiveness of maternal health care)
— Chronic care management: admission rates
for asthma, diabetes, epilepsy
Efficiency Achieving the desired results with the — Avoidable hospitalizations
[6]
most cost-effective use of resources
— Cost-per-case mix-adjusted separation
— Cost-effective prescribing
Safety Potential risks of an intervention or the — Hospital-acquired infection rate
[6]
environment are avoided or minimized
— In-hospital hip fracture rate
— Wrong-site surgery
— Medication errors
3.2.4 Community and health system characteristics (contextual information)
The dimension of community and health system characteristics contains contextual information which may be
useful for the interpretation of indicators and is described in Table 5. See Annex G for further information.
Table 5 — Community and health system characteristics
Sub-dimensions Description Examples of indicators
Resources Contextual information about financial, — Number of physicians per capita
physical, human or other types of (number of physicians to
resources population ratio)
— Provider compensation
— Asset ratios
— % expenditure on teaching
compared to service delivery
— % expenditure on research
Population Contextual information about the — % population over 65 years of
characteristics of the population age
— % residing in urban centres
Health system characteristics Contextual information about the — Health insurance enrolment
configuration, organization, sustainability
— Number of diagnostic imaging
or utilization of the health care system
procedures performed per capita
— Number of home care services
utilized per capita
— Ratio of fee-for-service physicians
to salaried physicians
3.2.5 Equity
Equity spans all dimensions of the framework and can apply to any of the concepts or indicators contained
therein. See Annex H for a description.

6 © ISO 2010 – All rights reserved

Annex A
(informative)
Correspondence with OECD health indicator initiatives
Other organizations are also involved in the development of health indicators on an international scale. The
OECD (Organization for Economic Co-operation and Development), for example, has several ongoing
initiatives directed at the measurement of health and health system performance. Undoubtedly, many aspects
of this International Standard overlap with OECD activities. At the same time, it is important to emphasize that
in many respects, this health indicators conceptual framework offers a unique and distinct contribution to
indicator frameworks used internationally.
The work of this International Standard and that of the OECD differ in both focus and scope. The ongoing
OECD initiatives tend to concentrate on specific health indicator definitions, data requirements and data
sources, all of which are outside the scope of this International Standard. In fact, it has been suggested that
[22]
the role of the OECD with respect to performance indicators encompass the following elements:
⎯ the identification of a common set of health outcome indicators;
⎯ standardization of concepts and data definitions;
⎯ application of these standards in national data infrastructure;
⎯ further analytical work using these data.
On the other hand, the utility of the present health indicators conceptual framework lies in the definition of a
taxonomy that is comprehensive and that can accommodate present as well as future data availability, yet
does not address specific indicators.
In order to frame the current definition and collection of OECD performance indicators, the OECD has
proposed a performance framework that also corresponds closely to the performance framework developed
by the WHO (World Health Organization) (see Reference [21]). The dimensions included in the proposed
OECD framework are presented in Table A.1. They are easily mapped to this International Standard's health
indicators conceptual framework. Yet, while the OECD framework targets selected dimensions, the framework
is broader and more comprehensive in scope.
Table A.1 — Mapping to OECD proposed performance framework
[21]
Proposed OECD concept of performance Mapping to health indicators conceptual framework
Quality (health improvement/outcomes) Health system performance — effectiveness
Responsiveness Health system performance — access and acceptability
Efficiency Health system performance — efficiency
Equity Access; can also be a component of all dimensions

The OECD has compiled internationally comparable health data for its member countries, focusing on health
status and health services inputs and throughputs. Here too, the data included in this compilation corresponds
to the health indicators conceptual framework without difficulty (see Table A.2). Again, the objective of the
framework is to define specific data elements and provide data, rather than the development of a single,
comprehensive, high-level taxonomy.
Table A.2 — Mapping to the OECD health data
OECD health data main data fields Mapping to health indicators conceptual framework
Health status Health status
Health care resources Community and health care system characteristics
Health care utilization Health status
Health system performance
Community and health care system characteristics
Expenditure on health Community and health care system characteristics
Financing and remuneration Community and health care system characteristics
Social protection Community and health care system characteristics
Pharmaceutical market Community and health care system characteristics
Non-medical determinants of health Determinants of health
Demographic references Community and health care system characteristics
Economic references Community and health care system characteristics

In 2001 the OECD launched the Health Care Quality Indicators (HCQI) Project. A framework was developed
[25]
within the scope of that project . Since it was based largely, although not exclusively, on the framework
presented here, and includes many of the same dimensions, there is a high degree of correspondence
between the two.
The current OECD initiatives are complementary to the health indicators conceptual framework presented by
this International Standard. While OECD work uses data and health indicators as a starting point and focus,
this International Standard proposes the creation of a framework at a conceptual level, eventually leading to
the identification of comparable and relevant data.

8 © ISO 2010 – All rights reserved

Annex B
(informative)
Rationale for a common health indicators conceptual framework
Why develop a common health indicators conceptual framework?
“Data and facts are not like pebbles on a beach, waiting to be picked up and collected. They can only be
perceived and measured through an underlying theoretical and conceptual framework, which defines
relevant facts, and distinguishes them from background noise.” Wolfson, Reference [56], p. 309.
It is possible to identify a myriad of potential “health indicators”, either in relation to what can easily be
generated from available data, or in terms of specific health goals, for example. However, if health indicators
are to be useful, at the local, national or international level, they must be chosen according to strict criteria
rather than in an a priori manner. In order for them to be informative, they must be able to accurately reflect
the fundamental elements of the system to be measured.
A conceptual health indicator framework can inform the selection and interpretation of meaningful health
indicators. Such a framework identifies what information is required to address questions about health and
health care, how these pieces fit together and the interrelationships between them.
In the international arena, a single agreed-upon health indicators framework would provide a constant
conceptual approach and definitions while allowing a great deal of flexibility in identifying specific indicators
and the underlying data requirements. Conceptual frameworks have proven useful as shared reference points
to enable comparable and consistent indicator reporting, and to facilitate communication between countries
about health information. Furthermore, this type of framework allows us to understand levels and differences
in health and health system performance, and to pinpoint the major factors which should be examined as a
requisite to translating this information into a health policy. A well-defined conceptual framework will also
foster a better understanding of which factors or outcomes may be contained within a health care system, and
which factors are remediable only through cross-sectoral collaboration.

Annex C
(informative)
Background on the health indicators conceptual framework
The health indicators conceptual framework specified within this International Standard is based on a
population health, or determinants of health, model. This framework reflects the principle, based on the
supporting scientific evidence, that health is determined by a complex interaction of factors, including the
social and physical environments, well-being, prosperity, health care, genetic endowment and individual
behavioural and biological response (see, for example, Reference [13] for a detailed discussion of this model).
In other words, according to the population health perspective, health is not determined solely by medical care,
but by a range of individual- and population-level cultural, social and economic factors. Although the term
population health has not been clearly defined, the implication is that an examination of health and health
policies must take account of a broad set of factors including, but not limited to, the provision of health
[26]
services .
If, in fact, health indicators are to be used for monitoring the health of the population vis à vis the performance
of the health care system, it is essential that we include, or are at least cognizant of, the “other” factors at play.
If these are not included, spurious conclusions about the relationships between health and health care can
1)
result . Since health care is part of a broader system where the individual parts are less meaningful than the
whole, one cannot attribute changes or patterns for many indicators to the health care system without first
[39]
looking at broader factors as well . Consider the following questions:
⎯ Are differences in access to preventive services, as evidenced by disparities in the use of screening
mammographies, attributable to health care system factors or differences in awareness that may be
linked to education?
⎯ Are differences in the prescription of generic drugs due to differences in providers, underlying morbidity or
differences in insurance coverage in the population?
⎯ Are differences in outcomes following hospital admission for heart attacks due to the variations in
treatment or to other factors?
In order to address such questions, the conceptual health indicators framework includes a broad spectrum of
factors for consideration. These may be associated with, but not necessarily due to, outcomes. It is not
possible to make a c
...