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Australian Pathology Messaging - Localisation of HL7 Version 2.4

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Australian Pathology Messaging - Localisation of HL7 Version 2.4 Australian Pathology Messaging - Localisation of HL7 Version 2.4 Sponsored by: The Royal College of Pathologists of Australasia (RCPA)/HL7 Australia HL7 Australia Orders and Observations Co-chairs: Michael Legg, RCPA and Michael Legg & Associates Andrew McIntyre, Medical Objects Editors Eric Browne, Montage Systems David McKillop, Australian Digital Health Agency Jared Davison, Medical Objects Donna Moore, RCPA Joint Copyright © 2016 Health Level Seven International ® and Health Level Seven Australia Inc ABN 35 556 933 588 ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publishers. HL7 International and Health Level Seven are registered trademarks of Health Level Seven International. Questions or comments regarding this document should be directed to Michael Legg ( [email protected]) or Andrew McIntyre ( a [email protected]) Table of Contents 1 Introduction 2 Patient Administration for Pathology 3 Datatypes 4 Observation Reporting 5 Observation Ordering 6 Identifiers Appendix 1 Parsing HL7v2 Appendix 2 Rendering of reports and display format Appendix 3 Common Errors Appendix 4 HL7 Code Tables Appendix 5 Conformance statements Appendix 6 Example messages Index of Tables Table 1-1. Message Element Attributes Table 1-2. Usage Conformance Testing Recommendations Table 6-1. Identifiers examples Table of Figures Figure 2-1. HL7 message segments Figure 3-1. HL7 data types by category Figure 3-2. Subcomponents of order sequences Figure 5-1. RU and RO usage (example) Figure 5-2. RQ and RO usage (example) Figure 5-3. Example of two child orders 1 Introduction Australian Pathology Messaging - Localisation of HL7 Version 2.4, Release 1 is the Australian localisation of the HL7 V2 Laboratory ordering and result reporting specification. The term pathology in Australia covers all aspects of laboratory medicine including clinical and anatomical pathology domains. The relationship between Pathology Practices and their customers in Australia is considered by Government and others as similar to that between other consultant specialists and their customers. For that reason what HL7 would call an order is generally called a request here and the response by the pathology provider (a formal term meaning the responsible specialist(s)) is called a report. For some disciplines such as microbiology, anatomical pathology, genetics and genomics the request is more by way of asking a clinical question expecting the pathology provider to understand the best way of answering it - eg Is this cancer, if so what type, and what is the prognosis? It is expected this form of requesting will become more common as laboratory medicine evolves. The use case here focuses on widely-available, well-standardized methods that will support the secure access to electronic laboratory orders and results and interpretations for clinical care by authorized parties and is driven by the need for timely electronic access to requested, referred and historical lab results. Requesting clinicians (the Placer) receive test results in the form of a HL7 V2 message, as a response to a request (electronic or paper) or as an unsolicited message by having the report directly sent by the pathology practice (the Filler) to the clinician for importation into their local systems. This document tries to provide coverage for all laboratory messaging scenarios in the Australian context including public and private entities, hospital and community and public health entities. The Royal College of Pathologists of Australasia (RCPA) has developed a number of policies around safety in requesting and reporting including the use of terminology and the transmission of data. These policies have been incorporated into this document. This document and the specifications in it supersede those in AS 4700.2-2012 - Implementation of Health Level Seven (HL7) Version 2.4 - Pathology and diagnostic imaging (diagnostics) and HB 262 (Rev)-2012 - Guidelines for messaging between diagnostic providers and health service providers. 1.1 Purpose This guide contains the necessary specifications for pathology requests and reports in Australian healthcare using the HL7 V2.4 protocol. Where appropriate aspects of later versions of HL7 V2 have been incorporated into this localization. Where this is done it is flagged as a variation from v2.4. 1.2 Audience This guide is designed for use by analysts and developers who require guidance on optional and ambiguous elements of an Australian constrained HL7 Version 2.4. Users of this guide must be familiar with the details of HL7 message construction and processing. This guide is not intended to be a tutorial on that subject. 1.3 Scope This specification covers the exchange of laboratory results from an appropriate requesting provider or organisation to the testing source and the transmission of the result from the testing source to the recipient. One of the primary features of this implementation guide is its focus on key points of broad interoperability. These key points include the following: Use of strong identifiers for key information objects – These information objects include patients, orders, providers and organizations. A strong identifier is one that uniquely identifies the object in question in a global fashion. This means the identifier includes enough information to remain unique when taken out of the context within which the identifier was created. For patients, providers and organsiations this is achieved through the use of the use of the Individual Healthcare Identifier (IHI), Healthcare Provider Identifier–Individual (HPI–I) and Healthcare Provider Identifier–Organisation (HPI–O). In places Medicare Provider numbers are used to provide for location specific provider identifiers. Healthcare Provider Identifier-Organisation (HPI-O) identifiers are not currently available for all organisations at the required level of granularity and alternative organisation identifiers are usually used. Use of Vocabulary Standards • This guide calls for specific vocabulary standards for the exchange of laboratory information. Use of standard vocabularies is important for a number of reasons. Use of standard vocabularies allows broad distribution of healthcare information without the need for individual institutions to exchange master files for data such as test codes, result codes, etc. Each institution ideally uses the standard codes or maps its own local vocabularies to the standard code, allowing information to be shared broadly, rather than remaining isolated as a single island of information. Standard vocabularies, particularly coded laboratory results, enable more automated decision support for patient healthcare, as well as more automated public health surveillance of populations. 1.4 Conventions This guide adheres to the following conventions: The guide is constructed assuming the implementer has access to the 2.4 version of the HL7 Standard. Although some information from the standard is included in this implementation guide, much information from the standard has not been repeated here. Data types have been described separately from the fields that use the data types. No conformance information is provided for optional message elements. This includes length, usage, cardinality, value sets and descriptive information. Implementers' who want to use optional message elements should refer to the HL7 Standard to determine how these optional message elements will be used. Use of optional message elements should not change the interpretation of data sent using the standard elements. The following table describes the various attributes used by this guide to document data type attribute tables, message structure attribute tables and segment attribute tables. Not all attributes apply to all attribute tables. Table 1-1. Message Element Attributes Attribute Definition Seq Sequence of the elements as numbered in the HL7 message element. The Seq attribute applies to the data type attribute table and the segment attribute table. Segment Three-character code for the segment and the abstract syntax (e.g., the square and curly braces). [ XXX ] Optional { XXX } Repeating XXX Required [{ XXX }] Optional and Repeating Note that for segment groups there is no segment code present, but the square and curly braces will still be present. The Segment attribute only applies to the Message attribute table. Length Maximum length of the element. Lengths are provided only for primitive data types. The length attribute applies to data type attribute tables and segment attribute tables. Lengths should be considered recommendations, not absolutes. The receiver can truncate fields, components and sub-components that are longer than the recommended length. The receiver should continue to process a message even when a field, component, or sub-component length exceeds the maximum recommended length identified in this specification. DT Data type used by this profile for HL7 element. The data type attribute applies to data type attribute tables and segment attribute tables. Usage Usage of the message element for this profile. Indicates whether the message element (segment, segment group, field, component, or subcomponent) is required, optional, or conditional in the corresponding message element. Usage applies to the message attribute table, data type attribute table and the segment attribute table. See HL7 International standard section C.3.1 – Usage for documentation on how usage has been implemented in this guide.
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