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Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4

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Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4 HL7 Australia Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4 HL7AUSD-STD-OO-ADRM-2021.1 HL7 Australia Limited Lvl 24,Tower 3, 300 Barangaroo Ave Barangaroo NSW 2000 Australia www.hl7.org.au Acknowledgements HL7 International This document includes excerpts of HL7® International standards and other HL7 International material. HL7 International is the publisher and holder of copyright in the excerpts. The publication, reproduction and use of such excerpts is governed by the HL7 IP Policy (see http://www.hl7.org/legal/ippolicy.cfm) and the HL7 International License Agreement. HL7 and CDA are registered trademarks of Health Level Seven International. Disclaimer HL7 Australia Limited makes the information and other material (‘Information’) in this document available in good faith but without any representation or warranty as to its accuracy or completeness. HL7 Australia Limited cannot accept any responsibility for the consequences of any use of the Information. As the Information is of a general nature only, it is up to any person using or relying on the Information to ensure that it is accurate, complete and suitable for the circumstances of its use. Document control This document is maintained in electronic form and is uncontrolled in printed form. It is the responsibility of the user to verify that this copy is the latest revision. Copyright © 2021 HL7 Australia Limited This document contains information which is protected by copyright. All Rights Reserved. No part of this work may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems—without the permission of HL7 Australia Limited. All copies of this document must include the copyright and other information contained on this page. Australian Diagnostics and Referral 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 Jared Davison, Medical Objects David McKillop, Australian Digital Health Agency Eric Browne, Montage Systems Brett Esler, Oridashi Vanessa Cameron, RCPA Joint Copyright © 2016-2021 Health Level Seven International ® and HL7 Australia Limited ABN 37 629 010 297 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 ( [email protected]) 1 mailto:[email protected] 2 mailto:[email protected] HL7AUSD-STD-OO-ADRM-2021.1 Copyright © 2021 HL7 Australia Limited 3 of 548 Australian Diagnostics and Referral Messaging - Localisation of Table of Contents HL7 Version 2.4 Table of Contents 1 Introduction (see page 7) 2 Patient Administration for Pathology (see page 21) 3 Datatypes (see page 119) 4 Observation Reporting (see page 201) 5 Observation Ordering (see page 277) 6 Identifiers (see page 301) 7 Patient Referral (see page 315) Appendix 1 Parsing HL7v2 (see page 373) Appendix 2 Rendering of reports and display format (see page 380) Appendix 3 Common Errors (see page 395) Appendix 4 HL7 Code Tables (see page 400) Appendix 5 Conformance statements (see page 416) Appendix 6 Example messages (see page 475) Appendix 7 Significant changes (Informative) (see page 480) Appendix 8 Simplified REF profile (Normative) (see page 482) Appendix 9 HL7v2 Virtual Medical Record (Normative) (see page 490) HL7AUSD-STD-OO-ADRM-2021.1 Copyright © 2021 HL7 Australia Limited 4 of 548 Australian Diagnostics and Referral Messaging - Localisation of Index of Tables HL7 Version 2.4 Index of Tables Table 1-1. Message Element Attributes (see page 9) Table 1-2. Usage Conformance Testing Recommendations (see page 13) Table 6-1. Identifiers examples (see page 311) HL7AUSD-STD-OO-ADRM-2021.1 Copyright © 2021 HL7 Australia Limited 5 of 548 Australian Diagnostics and Referral Messaging - Localisation of Table of Figures HL7 Version 2.4 Table of Figures Figure 2-1. HL7 message segments (see page 27) Figure 3-1. HL7 data types by category (see page 123) Figure 3-2. Subcomponents of order sequences (see page 179) Figure 5-1. RU and RO usage (example) (see page 285) Figure 5-2. RQ and RO usage (example) (see page 286) Figure 5-3. Example of two child orders (see page 287) HL7AUSD-STD-OO-ADRM-2021.1 Copyright © 2021 HL7 Australia Limited 6 of 548 Australian Diagnostics and Referral Messaging - Localisation of 1 Introduction HL7 Version 2.4 1 Introduction • 1.1 Purpose (see page 8) • 1.2 Audience (see page 8) • 1.3 Scope (see page 8) • 1.4 Conventions (see page 9) • 1.5 Key Words (see page 14) • 1.6 Related Documents (see page 14) • 1.7 Overview of Pathology Messaging (see page 16) • 1.8 ACKNOWLEDGEMENT PROCESSING (see page 20) Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4, Release 2 is the Australian localisation of the international HL7 V2 Standard covering the Laboratory/Diagnostics/Clinical result reporting, laboratory/radiology ordering specification and patient referral. The term "Diagnostics" covers non laboratory reporting including reporting of diagnostic imaging and non referral related clinical reporting (for example: echocardiography, respiratory function, endoscopy, stress testing, sleep studies). The term pathology in Australia covers all aspects of laboratory medicine including clinical and anatomical pathology domains, while the term “radiology” is understood to include all diagnostic imaging modalities, whether X-ray based or other (e.g. ultrasound). The relationship between pathology and radiology 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 - e.g. 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. In radiology, it is generally necessary for the request to include clinical information relevant to the purpose of the request, to enable the optimal choice, and interpretation, of the examination. It is also frequently necessary that the request contain information relevant to safety issues that may arise from performance of the test, such as contrast allergies, renal disease, etc. The use case here focuses on widely-available, well-standardized methods that will support the secure access to electronic laboratory and radiological requests 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. Images generated in the course of a radiological procedure are not sent in an HL7 message. Depending on the referrer’s requirements, and local technical capabilities, images may be made available on traditional analogue film (rapidly becoming obsolete), portable digital media, or, increasingly, in digital form via an online electronic portal. Referral messaging covers clinical referral between clinicians and hospitals, as well as hospital discharge and includes a patient history summary suitable for constructing a Virtual Medical Record for use in decision support and can include any pathology/radiology/diagnostics reports relevant to the referral. It also includes a Medication summary. This document tries to provide coverage for all laboratory and radiological messaging scenarios in the Australian context including public and private entities, hospital and community and public health entities. The referral messaging covers referral between medical practitioners, allied health and hospitals. It covers referral between practitioners, referral to hospitals and hospital discharge. The Royal College of Pathologists of Australasia (RCPA) has developed a number of policies around safety in requesting and reporting of pathology including the use of terminology and the transmission of data. These HL7AUSD-STD-OO-ADRM-2021.1 Copyright © 2021 HL7 Australia Limited 7 of 548 Australian Diagnostics and Referral Messaging - Localisation of 1 Introduction HL7 Version 2.4 policies have been incorporated into this document. Similarly, the Royal Australian and New Zealand College of Radiologists has defined minimum requirements for the content of referrals and reports. Standardised terminology for radiological procedures is being developed, and will be progressively implemented throughout the sector. This document and the specifications in it supersede
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