ISO/TS 21667:2004

TECHNICAL ISO/TS
SPECIFICATION 21667
First edition
2004-04-01

Health informatics — Health indicators
conceptual framework
Informatique de santé — Cadre conceptuel d'indicateurs de santé




Reference number
ISO/TS 21667:2004(E)
©
ISO 2004

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ISO/TS 21667:2004(E)
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ISO/TS 21667:2004(E)
Contents Page
Foreword. iv
Introduction . v
1 Scope. 1
2 Terms and definitions. 1
3 Health indicators conceptual framework. 2
3.1 Framework. 2
3.2 Equity framework dimensions. 2
3.2.1 Health status. 2
3.2.2 Non-medical determinants of health. 3
3.2.3 Health system performance. 4
3.2.4 Community and health system characteristics (contextual information). 5
3.2.5 Equity. 6
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 to the health indicators conceptual framework . 10
Annex D (informative) Health status. 12
Annex E (informative) Non-medical determinants of health . 13
Annex F (informative) Health system performance. 15
Annex G (informative) Community and health system characteristics (contextual indicators) . 16
Annex H (informative) Equity. 17
Bibliography . 18

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ISO/TS 21667:2004(E)
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 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:
 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;
 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 after three years in order to decide whether it will be confirmed for a
further three years, revised to become an International Standard, or withdrawn. If the ISO/PAS or ISO/TS is
confirmed, it is reviewed again after a further three years, at which time it must either be transformed into an
International Standard or be withdrawn.
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/TS 21667 was prepared by Technical Committee ISO/TC 215, Health informatics.
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ISO/TS 21667:2004(E)
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 be sensitive to variations over time and across jurisdictions.
In order for them to be useful for monitoring health or health system performance, however, explicit criteria
must be applied for choosing and defining health indicators. The selection must 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 we measure health and health
system performance. Here, a comprehensive, high-level taxonomy of the key types of indicators that are
useful for assessing population health and health services is described.
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 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.
This initiative can also be seen as complementary to work currently underway by other organizations — the
OECD, for example. 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,
non-medical determinants of health in the context of other essential factors.
See Annex A for more information regarding the OECD initiative and its relationship to this Technical
Specification's health indicators conceptual framework.

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TECHNICAL SPECIFICATION ISO/TS 21667:2004(E)

Health informatics — Health indicators conceptual framework
1 Scope
This Technical Specification establishes a common health indicators conceptual framework for the field of
health informatics. It is intended to foster a common vocabulary and conceptual definitions for a framework
which
 defines the appropriate dimensions and subdimensions required to describe the health of the population
and performance of a health care system,
 is sufficiently broad (high-level) to accommodate a variety of health care systems, and
 is comprehensive, encapsulating all of the factors that are related to health outcomes and health system
performance and utilization, and regional and national variations.
This Technical Specification does not identify or describe individual indicators or specific data elements for the
health indicators conceptual framework. As a next step, it has been proposed that a subsequent work item
address the metadata, or the characteristics and common attributes, of actual indicators that might be
contained in the health indicators conceptual framework.
The definition of benchmarks and/or approaches used in the definition of benchmarks is outside the scope of
this Technical Specification.
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 compliment to currently existing frameworks. For example, if a particular health indicators
framework currently focuses only on health system performance, the comprehensive approach suggested here may serve
to augment and/or supplement the currently used model(s).
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.
2 Terms and definitions
For the purposes of this document, the following terms and definitions apply.
3.1
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 is to be informative and also sensitive to variations over time and across jurisdictions.
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ISO/TS 21667:2004(E)
3 Health indicators conceptual framework
3.1 Framework
The health indicators conceptual framework, composed of four dimensions and their subdimensions and
considering equity, shall be as outlined in Table 1.
NOTE See Annex C for background information relating to the framework of Table 1.
Table 1 — Health indicators conceptual framework
Dimensions Sub-dimensions
1 Health status Well-being Health conditions Human function Deaths
2 Non-medical Health Socioeconomic Social and Environmental Genetic
determinants of behaviors factors community factors factors
health factors
3 Health system Acceptability Accessibility Appropriateness Competence
performance
Continuity Effectiveness Efficiency Safety
4 Community and Resources Population Health system
health system
characteristics
3.2 Equity framework dimensions
3.2.1 Dimension 1 — Health status
The dimension of health status is described in Table 2. See Annex D for further information.
Table 2 — Health status
Subdimensions Description Examples of
indicators
Well-being Broad measures of the physical, mental and social well-being of individuals  Self-rated
health
 Self-esteem
Health Alterations or attributes of the health status of an individual which may lead to  Arthritis
conditions distress, interference with daily activities, or contact with health services; it may
 Diabetes
be a disease (acute or chronic), disorder, injury or trauma, or reflect other
health-related states such as pregnancy, aging, stress, congenital anomaly, or
 Chronic pain
[45]
genetic predisposition .
 Depression
 Food and
waterborne
diseases
 Injury
hospitalization
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Equity

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ISO/TS 21667:2004(E)
Table 2 (continued)
Subdimensions Description Examples of
indicators
Human Levels of human function are associated with the consequences of disease,
 Functional
function disorder, injury and other health conditions; they include body function/structure
health
(impairments), activities (activity limitations, and participation (restrictions in
[45]  Disability days
participation) .
 Activity
limitation
 Health
expectancy
 Disability free
life expectancy
Deaths A range of age-specific and condition specific mortality rates, as well as derived
 Infant mortality
indicators.
 Life expectancy
 Potential years
of life lost
 Circulatory
deaths
 Unintentional
injury deaths
3.2.2 Dimension 2 — Non-medical determinants of health
The dimension of non-medical determinants of health is described in Table 3. See Annex E for further
information.
NOTE In order to enable a better understanding of geographic or temporal variations in health status and health
system performance, a variety of non-medical determinants of health have been included in the framework. Non-medical
determinants of health are those that fall outside of 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.
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ISO/TS 21667:2004(E)
Table 3 — Non-medical determinants of health
Subdimensions Description Examples of indicators
Health behaviors Aspects of personal behavior and risk factors that epide-  Smoking rate
miological studies have shown to influence health status.
 Physical activity
Socioeconomic Indicators related to the socioeconomic characteristics of the  Unemployment rate
factors population that epidemiological studies have shown to be
 Low income rate
related to health.
 High school graduation
Social and Measures the prevalence of social and community factors,  School readiness
community factors such as social support, life stress, or social capital that
 Social support
epidemiological studies have shown to be related to health.
 Housing affordability
 Literacy
Environmental Environmental factors with the potential to influence human  Water quality
factors health.
Genetic factors Factors outside those normally influenced by individual  Rates of genetically
behaviors or by the social, economic or physical environment; determined diseases (e.g.
genetic factors determine predisposition to certain conditions. Down's syndrome)
3.2.3 Dimension 3 — Health system performance
The dimension of health system performance is described in Table 4. See Annex F for further information.
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ISO/TS 21667:2004(E)
Table 4 — Health system performance
Subdimensions Description Examples of indicators
Acceptability All care/services provided meet the expectations of the client,  Patient satisfaction
community, providers and paying organizations, recognizing that
there may be conflicting, competing interests between
stakeholders, and that the needs of the clients/patients are
[5]
paramount .
Accessibility The ability of clients/patients to obtain care/service at the right  Waiting times
[5]
place and the right time, based on respective needs .
 Practice availability
 Availability of dentists
Appropriateness Care/service provided is relevant to the clients'/patients' needs and  Inappropriately used
[5]
based on established standards . surgery
 Appropriate use of ACEI
at discharge for heart
failure
Competence An individual's knowledge and skills are appropriate to the
—
[5]
care/service being provided .
Continuity The ability to provide uninterrupted coordinated care/service across
programs, practitioners, organizations, and levels of care/service, —
[5]
over time .
Effectiveness The care/service, intervention or action achieves the desired  Cancer survival
[5]
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 most cost-effective use of  Avoidable hospitalizations
[5]
resources .
 Cost per casemix-
adjusted separation
 Cost-effective prescribing
Safety Potential risks of an intervention or the environment are avoided or  Hospital-acquired
[5]
minimized . infection rate
3.2.4 Dimension 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.
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ISO/TS 21667:2004(E)
Table 5 — Community and health system characteristics
Sub-dimensions Description Examples of indicators
Resources Contextual information about financial, physical, human or  Number of physicians per capita
other types of resources.
 Provider compensation
 Asset ratios
 % expenditure on teaching
compared to service delivery
 % expenditure on research
Population Contextual information about the characteristics of the  Health insurance enrolment
population.
 % population over 65 years of
age
 % residing in urban centers
Health system Contextual information about the configuration, organization,  Number of coronary artery
sustainability or utilization of the health care system. bypass graft (CABG) per capita
 Number of home care services
provided per capita
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.
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ISO/TS 21667:2004(E)
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 the current ISO work item overlap with OECD activities. At the same time, it is important to emphasize that
in many respects, the proposed ISO health indicators conceptual framework poses a unique and distinct
contribution to this area of inquiry.
The work of this Technical Specification 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 of this proposal. In fact, it has been suggested that the role of the OECD with
[22]
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 this Technical Specification's health indicators conceptual framework lies in
the definition of a taxonomy that is comprehensive and 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
[20]
by the World Health Organization (WHO) . The dimensions included in the proposed OECD framework are
presented in Table A.1. It is easily mapped to this Technical Specification's health indicators conceptual
framework. Yet, while the OECD framework targets selected dimensions, this Technical Specification's
framework is broader and more comprehensive in scope.
Table A.1 — Mapping to OECD proposed performance framework
Proposed OECD concept of Mapping to proposed ISO health indicators conceptual framework
[20]
performance
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
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ISO/TS 21667:2004(E)
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
without difficulty to the health indicators conceptual framework (see Table A.2). Again, the objective of OECD
Health Data 2000 is to define specific data elements and providing data, rather than develop a single,
comprehensive, high-level taxonomy.
Table A.2 — Mapping to the OECD health data
OECD health data 2000 main data fields Mapping to proposed ISO health indicators conceptual framework
Health status Health status
Health care resources Community and health care system characteristics
Health care utilization 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 Non-medical determinants of health
Demographic references Community and health care system characteristics
Economic references Community and health care system characteristics
The current OECD initiatives are complementary to the health indicators conceptual framework within this
Technical Specification. While OECD work uses data and health indicators as a starting point and focus, the
SO framework is dedicated to the creation of a framework at a conceptual level, eventually leading to the
identification of comparable and relevant data.
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ISO/TS 21667:2004(E)
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
[50]
distinguishes them from background noise”
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, either 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 that we are attempting to measure.
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 allow for 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 a shared reference
point 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 health policy. A well-defined conceptual framework
will also facilitate 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.
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ISO/TS 21667:2004(E)
Annex C
(informative)

Background to the health indicators conceptual framework
The health indicators conceptual framework specified within this Technical Specification 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, as well as genetic endowment and
1)
individual behavioral and biological response . 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. 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 services (Frank 1995).
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 it can lead to spurious conclusions about the relationships between
2)
health and health care
...