1、Designation:E195905(Reapproved 2011)An American National StandardStandard Guide forRequests for Proposals Regarding Medical TranscriptionServices for Healthcare Institutions1This standard is issued under the fixed designation E1959;the number immediately following the designation indicates the year
2、oforiginal adoption or,in the case of revision,the year of last revision.A number in parentheses indicates the year of last reapproval.Asuperscript epsilon()indicates an editorial change since the last revision or reapproval.1.Scope1.1 This guide covers recommended guidelines to health-care institut
3、ions for the development and issuance of requestsfor proposals(RFPs),as well as guidelines for medicaltranscription service organizations(MTSOs)responding torequests for proposals.It does not purport to address all of thelegal aspects of the RFP,if any,associated with its use.It is theresponsibility
4、 of the user of this guide to establish appropriatelegal guidelines prior to use.1.2 It is appropriate for healthcare institutions to issue RFPsfrom time to time or at regular contractual intervals for thepurpose of facilitating the process of contracting for medicaltranscription services.1.3 It is
5、anticipated that both a commercial contract forservices and a HIPAA Business Associate Agreement will bebased upon the responding proposals submitted to the RFP.2.Referenced Documents2.1 ASTM Standards:2E1384 Practice for Content and Structure of the ElectronicHealth Record(EHR)E1762 Guide for Elect
6、ronic Authentication of Health CareInformationE1869 Guide for Confidentiality,Privacy,Access,and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE1902 Specification for Management of the Confidentialityand Security of Dictation,Transcription,and TranscribedHealth R
7、ecords(Withdrawn 2011)3E2117 Guide for Identification and Establishment of a Qual-ity Assurance Program for Medical TranscriptionE2184 Specification for Healthcare Document Formats(Withdrawn 2011)3E2344 Guide for Data Capture through the Dictation Process2.2 Other DocumentsAmerican Association for M
8、edical Transcription(AAMT),Metrics for Measuring Quality in Medical Transcription,20054AAMT Book of Style,Second Edition,20024Medical Transcription Industry Association(MTIA),BillingMethod Principles5Public Law 1004-191 Health Insurance Portability and Ac-countability Act of 1996(HIPAA)63.Terminolog
9、y3.1 Definitions:3.1.1 audit traila record of users that is documentaryevidence of monitoring each operation performed.Audit trailsmay be comprehensive or specific to the individual and event(that is,document routing,version control,access,etc.).3.1.2 authenticationprocess of(1)verifying authorship,
10、for example,by written signature,identifiable initials,orcomputer key,or(2)verifying that a document is what it ispurported to be,such as comparison with other records,orboth.3.1.3 Certified Medical Transcriptionistmedical transcrip-tionist who has met the qualifications for voluntary certifications
11、et by the American Association for Medical Transcription(AAMT),by demonstrating proficiency in the field,meetingaccepted standards,and maintaining the designation throughcontinuing education activities as required by the certificationprocess established by AAMT.3.1.4 compliance clauseitem in a contr
12、act that definesremedies for default of contract specifications.3.1.5 data destructioneradication of data to a useless andirretrievable state.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareInfo
13、rmation Capture and Documentation.Current edition approved July 1,2011.Published August 2011.Originallyapproved in 1998.Last previous edition approved in 2005 as E1959 05.DOI:10.1520/E1959-05R11.2For referenced ASTM standards,visit the ASTM website,www.astm.org,orcontact ASTM Customer Service at ser
14、viceastm.org.For Annual Book of ASTMStandards volume information,refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from American Association for Medical Transcription,www.aam-t.org.5Available
15、 from Medical Transcription Industry Association,.6Available from U.S.Government Printing Office,Superintendent of Docu-ments,732 N.Capitol St.,N.W.,Mail Stop:SDE,Washington,DC 20401.See alsohttp:/aspe.hhs.gov/admnsimp.Copyright ASTM International,100 Barr Harbor Drive,PO Box C700,West Conshohocken,
16、PA 19428-2959.United States1 3.1.6 data elementsunits of fundamental information froma healthcare record,organized in an analytical manner.3.1.7 data extractionspecification of a subset of data froma master data source for a new data format.3.1.8 data miningextraction of selected elements of storeddata to be used for a purpose other than the one for which theinformation was originally intended.3.1.9 dictationinformation that is stated or read aloud tobe transcribed by another.3.1.10 dictatorone
