HEALTH INFORMATION STANDARDS COMMITTEE FOR ALBERTA

Transcription

1 HEALTH INFORMATION MESSAGING STANDARD HEALTH INFORMATION STANDARDS COMMITTEE FOR ALBERTA DIAGNOSTIC IMAGING TEXT AND OTHER TRANSCRIBED REPORTS MESSAGE SPECIFICATION Status: Accepted in Draft Version 0.4 Status Date: August 12, 2009

2 On September 16, 2009 the Health Information Standards Committee for Alberta (HISCA) Accepted in Draft, three (3) Diagnostic Imaging submissions including the Alberta Diagnostic Imaging Reporting Requirement, the Diagnostic Imaging Text and other Transcribed Reports Message Specification, and the Alberta Diagnostic Imaging HL7 Message Specifications. These submissions are now required to be reviewed by peers and other interested parties as a part of the HISCA process. Following this review, Stakeholder feedback will be consolidated and presented back to the project teams for consideration and/or dispute resolution. Please find and review the attached copies of the submissions and return your comments or concerns to the HISCA secretariat at HISCA@gov.ab.ca. Request for Comments until October 28, Once again, thank you for your assistance. Susan Anderson, Chair Health Information Standards Committee for Alberta Date

3 VERSION HISTORY Version Version Date Summary of Changes Changes marked Sep-30 Draft No Nov-21 Accepted in Draft No May-31 Include ORC segment in the message specification. Only the MWB (ORU_R01) file is revised to include the ORC segment as an optional segment in the message structure. The MWB (MDM) message structure does not support ORC segment and hence MDM profile was not revised. The ORC segment has Order Control field as the only entry and references HL70119 table. No Dec-31 Include EVN Event Type segment in the MDM message profile. No MDM messages sent to CH by ACB contain EVN segment Aug-12 Fix Source Table specification in the ORU message. The fix affects the following fields: - Principal Result Interpreter - Technician - Transcriptionist

4 TABLE OF CONTENTS GENERAL OVERVIEW...1 BUSINESS PROCESS OVERVIEW...2 PROCESS FLOW...3 REPORT DESCRIPTION...3 Diagnostic Imaging Text Report...3 Operative Report...4 Patient History Report...4 Consultation Report...5 Discharge / Obstetrical Discharge Summary Report...6 Report of Procedure...7 E.E.G. Text Report...7 Clinic Report / Progress Note...8 Letter...9 E.C.G. Text Report...9 REPORT PROCESS...11 Process Flow...11 Actors...12 Precondition...12 Narrative...12 Alternative Flow...13 Post Condition...13 USE CASES SPECIFICATION...14 Use Case Diagram...14 Use Case: Communicate Transcribed Report (Ref# UC01)...14 Use-Case: Communicate DI Text Report (Ref# UC02)...16 TRANSACTION SUMMARY...18 OVERVIEW...18 MDM_T Message Purpose...18 Message Rules...18 Transaction Messages...22 Error Conditions...22 ORU_R Message Purpose...23 Message Rules...23 Transaction Messages...23 Error Conditions...23 TRANSACTION MESSAGE DETAIL...24 SECTION GUIDE...24 Characteristics...24 Profile Type...24 Interactions...24 Message Characteristics...24 Segment and Segment Group Definitions...25 Segment Table...26 Segment Element Details...27 General Notes...28

5 MDM MESSAGE SPECIFICATION...29 MDM - Transcribed Reports Delivery Message Specification...29 MSH - Message header segment...30 EVN Event Type segment...33 PID - Patient Identification...34 PV1 - Patient visit...37 TXA - Transcription document header segment...41 Report Content...47 OBX Observation Segment...47 End Report Content...48 ORU MESSAGE SPECIFICATION...49 ORU - Diagnostic Imaging Text and Other Transcribed Reports Delivery Message Specification...49 MSH - Message header segment...50 PID - Patient Identification...53 PV1 - Patient visit...56 ORC Common Order Segment...60 OBR Observation Request Segment...61 Report Content...67 OBX Observation Segment...67 End Report Content...68 TRANSACTION MESSAGE TABLES...69 HL70001 SEX (USER)...69 HL70003 EVENT TYPE (HL7)...69 HL70004 PATIENT CLASS (USER)...75 HL70062 EVENT REASON (USER)...75 HL70076 MESSAGE TYPE (HL7)...75 HL70103 PROCESSING ID (HL7)...78 HL70104 VERSION ID (HL7)...78 HL70123 RESULT STATUS (HL7)...79 HL70125 VALUE TYPE (HL7)...79 HL70136 YES/NO INDICATOR (HL7)...80 HL70270 DOCUMENT TYPE (HL7)...80 HL70271 DOCUMENT COMPLETION STATUS (HL7)...81 HL70396 CODING SYSTEM (HL7) PROVINCIAL CODES (USER)...83 ERROR CONDITIONS...84 HL7 DATA TYPES...85 GLOSSARY...89 APPENDIX A - REPORT DATA ELEMENT MAPPING TO HL7 SEGMENT/FIELDS...90 Common Elements to MDM and ORU Domain...90 Elements Different in MDM and ORU Domain...90

6 GENERAL OVERVIEW This document presents the message specifications for the Diagnostic Imaging Text and Other Transcribed Reports Message Specification project. The standardized set of message specifications detailed in this document will minimize the development effort required for sending and receiving Diagnostic Imaging Text and Other Transcribed Reports. This project is the result of needs identified by the Alberta Health System IM/IT Electronic Health Record (EHR) Strategic Plan to deliver Diagnostic Imaging Text and Other Transcribed Reports to Physician Office Systems electronically within the province of Alberta. For this project, Alberta Health and Wellness (AHW) formed a Diagnostic Imaging Text and Other Transcribed Reports Working Group (DITR WG) including the following groups and organizations: 1. Capital Health, 2. Calgary Health Region, 3. Regional Shared Health Information Program (RSHIP), 4. Alberta Cancer Board, 5. Physician Office System Program (POSP), 6. Canadian Healthcare Information Technology Trade Association (CHITTA), and 7. Alberta Health and Wellness The project team worked with the DITR WG to refine and developed a Health Level 7 (HL7) message specification that is to be used for the electronic delivery of Diagnostic Imaging Text and Other Transcribed Reports (DITR). A standard message specification developed by the Project team and presented in this document is a result of this cooperation and workshops that were on July 19, August 3 and 17, and September 8, 21, 30, This document is comprised of two components: 1. A Process Flow, including diagrams, narrative describing each type of the report, workflow, use case model, description of the user-to-system interactions, and mapping between report data elements and HL7 fields. 2. A Message Profile, including transaction message details, transaction message tables and HL7 data types. Also, this section provides detailed descriptions for Unsolicited Transmission Of An Observation Message (ORU) and Medical Document Management message specifications (MDM) Government of Alberta Page 1 of 97

7 BUSINESS PROCESS OVERVIEW The purpose of this message specification is to provide a design standard for electronic transmission of diagnostic imaging textual reports and other transcribed reports from Regional Health Authorities and Alberta Cancer Board to the Physician Office Systems (POS) and/or Electronic Medical Record (EMR). The standardized set of message specifications described in this document will minimize the development effort required for sending and receiving Diagnostic Imaging Text and Other Transcribed Reports. Currently, there are two message domains used in the province of Alberta - Observation Reporting (OBR and OBX) for transcribed reports and Document Management (MDM and TXA). The DITR WG has decided to build two message specifications and to support two message domains for this project as presented below: 1. MDM - This message is used to transport electronic copies of Transcribed Reports from the Regional Health Authority (RHA) to a Designated Report Repository allowing the appropriate EMR to pick up the transcribed reports on a predefined schedule. This message supports the transmission of a new or updated document. The MDM message is concerned primarily with the management of documents, which are created as a result of the transcription process. 2. ORU - This message is used to transport electronic copies of Diagnostic Imaging Text and Other Transcribed Reports from an RHA facility to the appropriate Physician Office System(s) (POS). Note: The message specifications presented in this document are based on the DI Text and Transcribed Reports Message Specification (Alberta Health and Wellness, March 31, 2005) recommendations Government of Alberta Page 2 of 97

8 PROCESS FLOW The Process Flow illustrates the workflow of reports from origination to destination. It also identifies each actor (i.e. a person/position or system) involved and the key activities they perform in completing the process. The Process Flow provides the framework to understanding the context and requirements of each message. The Process Flow includes: A short description of each report; A Process Map (a flowchart illustrating the process activities); A list and description of the actors who will participate in the process; A Storyboard (a narrative describing the activities performed by each actor in the process); and A Use Case. Note: The Storyboard text includes numbers in brackets. These numbers correspond to activities described in the process map. REPORT DESCRIPTION DIAGNOSTIC IMAGING TEXT REPORT The Diagnostic Imaging Text Report is dictated after the diagnostic imaging exam is completed. The exam is performed during the current treatment of the patient or any follow-up for a patient s condition. The report is dictated by the radiologist, nuclear medicine physician, or resident doctor. The report indicates what imaging/procedure was completed, any findings from the study, the radiologist s diagnosis text and code, and any further recommendations/follow-up that are required. The report includes such data as the date & time of the examination, patient s first & last name, demographics, chart number, diagnostic imaging (DI) number, date of birth (DOB), provincial health number (PHN), inpatient/ outpatient (IP/OP) information, emergency information, clinic location, address, phone, and name of facility. Report copies are distributed as requested by the author of the report. Possible receivers of this report are: attending physician (hospitals), ordering physician (emergency), family physician, referring physician (medical centre), or any other doctors that are specified by the dictator of the report. In order for any recipient to receive a copy, the author must request that a copy be sent to them. Pediatric and Gynecological patient reports are only sent to the requesting physician no other copies are sent. Exceptions: Capital Health Region No Exceptions Calgary Health Region Exception # 1 There is no restriction that Pediatric and Gynecological patient reports are only to be sent to the requesting physician. Exception # 2 A report copy is sent by default to the family physician and ordering physician Government of Alberta Page 3 of 97

9 Regional Shared Health Information Program Exception # 1 There is no restriction that Pediatric and Gynecological patient reports are only to be sent to the requesting physician. Exception # 2 A report copy is sent by default to the family physician and ordering physician. Alberta Cancer Board No Exceptions Additional information: Sometimes an exam is incomplete or unsuccessful, but a report is still dictated to make the physician aware of the situation. OPERATIVE REPORT The Operative Report is dictated after a patient has either an inpatient or day surgery procedure with general anesthetic as part of his/her treatment. The admission can be an elective, emergency, etc. The report is dictated by the attending surgeon or a resident who dictates the report on behalf of the surgeon. The report describes the procedure that was performed, the preoperative & postoperative diagnoses, and operative findings. It contains the surgeon s impression of the procedure and the result of the operative procedure. The report may also contain diagnosis and recommendations for follow-up. The report contains such data as the responsible surgeon and other significant participants (assistants, anesthetists, etc.), patient s first & last name, patient s demographics, chart number, DOB, PHN, location, name of facility, date of procedure, postoperative plan, and listing of copies. Report copies are distributed as requested by the author of the report. The report may be received by anyone involved in direct care post-surgery. The recipient list may include a family physician, referring physician, or any other physician that the surgeon specifies. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: If an Operative Report has not been dictated when the patient has been discharged, the chart is considered deficient until the report is dictated and filed on the chart. PATIENT HISTORY REPORT The Patient History Report is dictated after a patient is admitted to the hospital for a disease, illness or other condition requiring further treatment and follow-up in the hospital. The report is dictated by the admitting physician, resident, or student intern. The report is created after an initial examination/admission or preoperational consultation Government of Alberta Page 4 of 97

10 The report documents all the previous and present medical, physical and surgical history of the patient. The report contains a general description and assessment of the current conditions and complaints of the patient and provides a summary of past medical events and problems. The report may contain list of medications, allergies, past medical history, and family & social history. Additionally, the report may provide the reason for the patient s admission and possible diagnoses, preliminary laboratory and DI investigations, treatment plan and possible referrals for confirmation of diagnoses. The report contains such data as the admission date, the examining physician (including his or her signature), the patient s first & last name, chart number, DOB, PHN, location, name of facility (hospital or clinic), patient s demographics, the name of the author of the report, and listing of copies. Report copies are distributed as requested by the author of the report. The receiving list may include the admitting physician, family physician, or any other physician that the admitting physician specifies. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. The receiving physicians may refer the patient to another specialist for further consultation depending on what the illness or disease is. Exceptions: Capital Health Region Exception # 1 - In most cases, copies of the transcribed history are not sent out. The majority of histories transcribed for the Capital Health Region are for inpatients and only one copy is printed for the patient's chart. There are a few exceptions to this rule and these exceptions are specific to a site (i.e. Royal Alexandra Hospital, Rural Hospitals, etc). Calgary Health Region Exception # 1 Very few histories are transcribed; they are either provided by the admitting physician s office or are hand written on site. Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: None CONSULTATION REPORT The Consultation Report is dictated after a patient visits a specialist (consulting physician) as per a consultation request by the attending physician. The attending physician needs advice for further treatment and follow-up of a disease, injury or investigation pertaining to the patient s condition. The report is dictated by the consulting physician, resident, student intern, or nurse. The Consultation Report can be initial and repeat. This report provides expert opinions, impressions, a diagnosis, modified treatment plan and recommendations for care or treatment if appropriate. It may contain list of medications, allergies, past medical history, and family & social history, or initiate further testing or surgery. The report contains such data as the report date, the consultant s name, identification of the attending physician and the associated hospital or clinic. It provides the patient s first & last name, patient s demographics, chart number, DOB, PHN, room, location, name of facility, and listing of copies. Report copies are distributed as requested by the author of the report. The list may include the admitting/referring physician, consultant, family physician, or any other doctors that the consulting physician specifies. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: 2009 Government of Alberta Page 5 of 97

11 Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: The Consultation Report is sometimes hand written. DISCHARGE / OBSTETRICAL DISCHARGE SUMMARY REPORT This report is created following a patient s discharge from the hospital after having the necessary treatment and management or, in the case of the obstetrical discharge, after a patient has had a delivery and confinement. The report is dictated by the most responsible physician, the admitting physician, the nurse practitioner, the resident, or the clinical clerk on behalf of the physician, or by the obstetrician (if discharge is obstetrical). The report gives an overview of the medically significant events that have occurred over the course of a clinical encounter. It may contain the list of medications, performed procedures, any allergies, medical history, family & social history, physical exam information, summary of present complaint, discharge diagnosis, diagnosis most responsible for stay, other diagnosis, any complications, follow-up recommendations in the community, and treatment plan. The obstetrical discharge report provides a summary of the obstetrical encounter, the care provided during an episode of care, treatments, procedures, medications, consultations and diagnostic procedures. Also, it contains information about a baby and primary mother. The report includes such data as the admission & discharge dates, the reason for admission, the name of the author of the report, listing of copies, the patient s first & last name, patient demographics, chart number, DOB, PHN, clinic location, and name of facility. Report copies are distributed as requested by the author of the report. A report copy is sent to the most responsible physician (i.e. surgeon if an OR is performed). The receiving list may contain a family physician, follow-up specialist, community health nurse, referring physician, or any other physician specified by the dictator of the report. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region Exception # 1 A "Short-Stay" form is used. This is a hand written summary that provides physicians with details about a patient's stay. This form can only be used for a stay that is less than 2 days or thereabouts. Calgary Health Region Exception # 1 A Delivery Note template is used. (Note: this template is categorized under the Operative Report type and is not a Discharge Summary.) Regional Shared Health Information Program 2009 Government of Alberta Page 6 of 97

12 Exception # 1 A Delivery Report is created describing the birth and physical examination of the baby after the patient has had a normal delivery and confinement. A Discharge Summary is then created with any outpatient follow-up. Alberta Cancer Board No Exceptions Additional information: Discharge Summary and Obstetrical Discharge Summary reports can use the same template a newborn baby would normally go under mother unless there are complications then they get their own discharge summary report. This decision is under physician s discretion. Specific tumor groups require discharge letters be sent to the General Practitioner (GP) and the patient. REPORT OF PROCEDURE The Report of Procedure is dictated after a patient has had a day surgery or a minor, elective procedure for which no general anesthetic is required. If diagnosis is chronic, the procedure could be a part of continuing care for the patient. The report is dictated by the obstetrician, radiologist, nuclear medicine physician, resident, or student intern. The report summarizes the elements of a medical procedure performed on the patient. The report provides a narrative description of the procedure, diagnosis, the short clinical history, type of procedure performed, and findings. It may provide differential diagnoses pending path results and therapies. The report contains such data as the patient s first & last name, chart number, DOB, PHN, clinic location, and the name of the facility, Report copies are distributed as requested by the author of the report. The receiving list may include a family physician, referring physician, surgeon, and/or attending physician. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: Some procedures depicted by this report are: colposcopy, biopsy, caesarian section delivery, and gastroscopy. The report s outcome may indicate follow-up treatment. Frequently, the report is followed up by post imaging report. E.E.G. TEXT REPORT The Electroencephalogram (E.E.G.) Text Report is dictated after the E.E.G. is completed and sent to the interpreting physician to detail the results. The report is created by the neurologist who interprets the E.E.G. exam and tracings. The neurologist has to be qualified and accredited (CPSA) to interpret E.E.G. s Government of Alberta Page 7 of 97

13 The report summarizes the neurologist s interpretation of the E.E.G. results, the procedure performed, and the diagnosis. It contains such data as the date & time of the examination and report generation, the patient s first & last name, demographics, chart number, DOB, PHN, clinic location, address and phone, the name of the author of the report, and listing of copies. Report copies are distributed as requested by the author of the report. Possible receivers are: attending physician (hospitals), referring physician (medical centre), or any other doctors that are specified. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: This report is similar to the Diagnostic Imaging Text report. CLINIC REPORT / PROGRESS NOTE The Clinic Report / Progress Note is created when the patient is referred to and examined by a specialist in an outpatient clinic in the hospital during the patient s current treatment. The report is dictated by the consulting physician from the clinic, by a resident, nurse, or other allied health professional (physiologist, social worker, speech therapist, audiologist, etc.). The report provides summary of the patient s progress to date and further treatment required. It may contain list of medications, allergies, past medical history, family & social history, physician exam information, and summary of present complaint. Additionally, the report contains such data as the identification of the hospital or clinic, the responsible physician and other significant participants in the procedure, the patient s first & last name, demographics, chart number, DOB, PHN, and listing of copies. Report copies are distributed as requested by the author of the report. Possible receivers may be a family physician, referring physician, individuals involved in the patient s care, and responsible specialist. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board 2009 Government of Alberta Page 8 of 97

14 Exception # 1 A Progress Note is used instead of a Clinic Report. Additional information: A Clinic report can be generated by a number of different clinics including; dermatology, ear, nose & throat, arthritis, neurology, and gerontology. LETTER The Letter Report is created when a physician decides to communicate information to another physician, specialist, clinic, hospital, or other health authority. This type of a report is very generic: it communicates information to other entities for any purpose the physician desires. The report can be dictated by the consulting physician from the clinic, the treating physician, nurse, or other allied health professional (physiologist, social worker, speech therapist, audiologist, etc.). The report generally provides information regarding the patient s diagnosis and care. It may contain, among others, list of medications, allergies, past medical history, family & social history, physician exam information, and summary of present complaint. Report copies are distributed as requested by the author of the report. Possible receivers may be a family physician, referring physician, or any other external entity regarding any aspect of the care, treatment, access, insurability or personal aspect of medical care. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them. Exceptions: Capital Health Region Exception # 1 Not all letters are signed before distribution. Exception # 2 Letters are not completed for patients in the acute care setting, inpatients, day surgeries, etc. Calgary Health Region No Exceptions Regional Shared Health Information Program No Exceptions Alberta Cancer Board No Exceptions Additional information: Report copies are still manually signed by the author of the letter and are not distributed until the author has signed each copy of the letter. This report is similar to the Clinic report except it is more personalized. E.C.G. TEXT REPORT The Electrocardiogram (E.C.G. Text Report is created when an E.C.G. exam is completed and the cardiologist interprets the results. The cardiologist must be an approved interpreting physician. The report communicates the diagnostic results of an E.C.G. including impressions and recommendations of the cardiologist to provide evidence based care of the patient. It contains the cardiologist s diagnosis text and code, the patient s first & last name, demographics, chart number, DOB, PHN, the date & time of the examination and generation of the report, clinic location, address and phone, and listing of copies. The report is distributed as requested by the author of the report. The distribution list may include the referring or ordering physician. However, in order for any recipients to receive a copy, the author must request that a copy be sent to them Government of Alberta Page 9 of 97

15 Exceptions: Capital Health Region No Exceptions Calgary Health Region No Exceptions Regional Shared Health Information Program Exception # 1 - For outpatients, copies are sent to the ordering physician, the cardiologist, and any other physician that the ordering physician requests. For inpatients, copies are sent to: the ER, the Outpatient Department, the Preadmission Clinic, the Cancer Clinic, the Nursing Ward, and to Cardiology. Alberta Cancer Board No Exceptions Additional information: This report is similar to the Diagnostic Imaging Text report Government of Alberta Page 10 of 97

16 Report Process PROCESS FLOW START 1 Author dictates report into a dictation system 2 Transcriptionist accesses voice server for report 3 Transcriptionist transcribes report to a word processing application and sets version Report complete? YES Transcriptionist saves report in electronic and/ or hard copy Transcriptionist attaches note to the report Review, verification, or signature required? YES NO NO YES 8 9 Owner reviews report Correction required? YES 10 Owner makes corrections to the report 11 Owner sends report for transcription? 12 Owner verifies and/or signs off report NO NO 13 Report messaging initiator triggers message generation 14 Messages are forwarded to the message management system Message management system determines the recipient Recipient information valid? NO YES Message management system delivers messages System error? YES 19 System administrator resolves error NO Messages are unpacked into reports Owner / recipient(s) receive report END Legend: Processes presented with white boxes are in the scope of the project and related to use cases REF# UC1 and REF# UC Government of Alberta Page 11 of 97

17 ACTORS ACTOR NAME Author Owner Recipient DESCRIPTION Any person who dictates the report physician, resident, nurse etc. A person with health authority to verify and sign off the report (for example, a resident can dictate the report on behalf of the surgeon, but the report has to be verified by the surgeon who performed surgery) Persons, organizations, or clinics listed as receivers by the author of the report Report Messaging Initiator A person/system responsible for initiating/triggering a message generation transcriptionist, system administrator, or system scheduled event PRECONDITION The Author of the report decides to dictate summary information regarding an exam, surgery, hospital admission, consultation, discharge, surgery, or examination by a specialist. NARRATIVE The Author dictates the report into a dictation system (1). The Transcriptionist accesses the voice system (2) and types the report using a word processing application (3). At this point, the report version is identified by either setting a date and time, or version/revision number (depending on the business rules defined by region or facility). Every report can be redistributed / modified several times and the version determinates each of them (3). If the report is not completed (4), the Transcriptionist attaches a note to the report stating what is missing (6). Both, complete and incomplete reports are saved in electronic and/or hard copy (5). In some regions, the report must be reviewed, verified and/or signed off by a physician or the other health authority responsible for the content of the report. If this verification is not required (7), the transcribed report is further processed (13). Otherwise, the report is reviewed (8) by the Owner of the report (a person / physician with authority to verify and sign off the report). The Owner may correct the report (9, 10) and send it back to the Transcriptionist (11, 3) for update, or the Owner may modify the report himself (12) after which the report is ready for messaging process (13). Both, verified and non-verified reports are processed by a message system (13). The process could be a scheduled event or initiated by the Report Messaging Initiator, who may be any person responsible for triggering this procedure for example, a system administrator. Messages are then forwarded (14) to a message management system responsible for the report distribution. If any system error occurs (18), the system administrator resolves the issue and restarts the process (19). Finally, messages are formatted into reports (20) and delivered to the Recipients (21). Currently, the report is distributed electronically, by auto fax, or by mail to the Recipients. The Author of the dictated report automatically receives a copy. In order for any other Recipients to receive a copy, the Author must request that a copy be sent to them. It is critical that the Author provides the complete name of the physician/recipient (16). For example, requesting a copy to be sent to the family physician is not sufficient - the Author must dictate the name and other details. The report will only be issued if the Recipient s information is accurately captured (15, 16, and 17). If reports do not have the Recipient information, they will be ignored with no feedback to the sending system. Reports without sufficient data are dismissed and excluded from the process of distribution. Only valid reports are received (21). After receiving the report, the Owner may revise/addend and/or verify the report and send it to the Transcriptionist for update and redistribution. Note that this process can occur more than once a report can be revisited several times and, consequently, can have several versions (3) Government of Alberta Page 12 of 97

18 ALTERNATIVE FLOW In the Calgary Health Region, transcribed reports are not held for the author to review and verify before distribution. The electronic signature is not currently available in this region. Once a report is transcribed, it is wrapped up and is automatically distributed. If there are blanks in the report, an e-sticky note is attached to the report requesting the author to complete the blanks and fax it back to the transcription department. When the report is returned, a transcriptionist brings up the report, fills in the blanks and redistributes the report. If there is a correction or addendum, the author returns the report to the department where the report is revisited and redistributed. A physician may receive several versions of a report. In the Calgary Health Region, the second copy of the DI Text Report is sent after report is verified regardless if any changes are made. In the Capital Health Region, most DI reports have electronic signature availability. In the Capital Health Region, different processes are used by each hospital site. For the electronic health record (NetCARE), all documents once typed can be viewed by individuals who have access. Therefore if the hard copy is not distributed, it is still accessible. If there is nothing wrong with the typed report (no missing information, etc), copies are distributed either by mail or by an autofax function (batch faxing). In some cases, copies are not distributed until the report is signed. POST CONDITION The report is filed in the Owner s/ Recipient s filing system Government of Alberta Page 13 of 97

19 USE CASES SPECIFICATION USE CASE DIAGRAM Transcription System Communicate Transcribed Report Communicate DI Text Report POS/EMR RIS USE CASE: COMMUNICATE TRANSCRIBED REPORT (REF# UC01) BRIEF DESCRIPTION The Communicate Transcribed Report process enables the transport of electronic copies of Transcribed Reports from the Regional Health Authority to a Designated Report Repository allowing the appropriate POS/EMR to pick up the transcribed reports on a predefined schedule. This process allows communication of the following report types: 1. CD (Cardiodiagnostics) 2. CN (Consultation) 3. DS (Discharge summary) 4. ED (Emergency department report) 5. HP (History and physical examination) 6. OP (Operative report) 7. PN (Procedure note) 8. PR (Progress note) 9. SP (Surgical pathology) 10. LT (Letter) Note: The above types are stored in the HL70270 Document type table HL Government of Alberta Page 14 of 97

20 Primary Actor: Transcription System A.1.I.1 A.1.I.2 Basic Flow of Events 1. This use case is triggered when the Transcription System generates a message batch. 2. The Transcription System sends the message batch to the Designated Report Repository. 3. The Designated Report Repository validates the batch according to the message specification document. 4. The Designated Report Repository commits the batch file to a safe storage and sends an acknowledgement to the Transcription System 5. The Designated Report Repository determines the recipients of the Transcript Report. 6. The Designated Report Repository enables the appropriate POS/EMR to pick up the transcribed reports on a predefined schedule. 7. An audit trail and archive record is created. Alternative Flows A.1.I.2.1 Validation process is not successful. If, at step 3 of the Basic Flow, the system determines that data is not valid: 1. The system creates an error notification to the Transcription System. 2. Reports identified as invalid are not processed further. 3. The use case resumes at step 3. A.1.I.3 Special Requirements The following message domain specifications apply to this process: MDM ORU A.1.I.4 Preconditions Reports are transcribed; report messages are generated, validated and ready to be communicated to the POS/EMR. A.1.I.5 Postconditions The POS/EMR receives the message reports successfully and reports can be obtained by the receiver. A.1.I.6 Additional Information Secondary Actors: POS/EMR. Offstage Actors: Health Records Government of Alberta Page 15 of 97

21 USE-CASE: COMMUNICATE DI TEXT REPORT (REF# UC02) A.1.I.7 Brief Description The Communicate DI Text Report process enables the transport of diagnostic imaging text reports from the Regional Health Authority to a Designated Report Repository allowing the appropriate POS/EMR to pick up the reports on a predefined schedule. This process enables communication of the following report type: 1. DI (Diagnostic imaging) Note: The above type is stored in the HL70270 Document type table HL7. Primary Actors: Radiology Information System (RIS) / Transcription System A.1.I.8 A.1.I.9 Basic Flow of Events 1. This use case is triggered when the RIS / Transcription System generates a message batch. 2. The RIS or Transcription System sends the report batch file to the Designated Report Repository. 3. The Designated Report Repository validates the message according to the message specification document. 4. The Designated Report Repository commits the message to a safe storage and sends an acknowledgement back to the RIS/Transcription System 5. The Designated Report Repository determines the recipients of the diagnostic imaging text report. 6. The Designated Report Repository enables the appropriate POS/EMR to pick up the diagnostic imaging text report on a predefined schedule. 7. An audit trail and archive record is created. Alternative Flows A.1.I.9.1 Validation process is not successful. If, at step 3 of the Basic Flow, the system determines that data is not valid: 1. The system creates an error notification to the RIS/Transcription System. 2. Reports identified as invalid are not processed further. 3. The use case resumes at step 3. A.1.I.10 Special Requirements The following message domain specifications apply to this process: ORU A.1.I.11 Preconditions Report messages are generated, validated and ready to be communicated to the POS/EMR. A.1.I.12 Postconditions The POS/EMR receives the message reports successfully and reports can be obtained by the receiver. A.1.I.13 Additional Information Secondary Actors: POS/EMR Government of Alberta Page 16 of 97

22 Offstage Actors: Health Records Government of Alberta Page 17 of 97

23 TRANSACTION SUMMARY OVERVIEW This section provides detailed descriptions for ORU - Unsolicited Transmission Of An Observation Message and MDM Medical Document Management message specifications. Each message specification will contain the following sections: Message Purpose This section describes what task the message performs. It also explains the circumstances in which the message should be used. Message Rules This section outlines specific business rules governing the message use and construction. Transaction Messages This section lists the HL7 message structures. For each message, the name of the message is linked to the detailed message specification in Section E Transaction Message Details. Error Conditions This section indicates any non-general messages that may apply to the implementation of the message. Additional details on the error messages can be found in Section G - Error Conditions. MDM_T02 MESSAGE PURPOSE This message is used to transport electronic copies of Transcribed Reports from the Regional Health Authority to a Designated Report Repository allowing the appropriate EMR to pick up the transcribed reports on a predefined schedule. This message supports transmission of a new or updated document and status of the report. The medical document management message is concerned primarily with the management of documents, which are created as a result of a transcription process. These documents are created in two distinct contexts, one of which are related to an order, describing the procedures or activities associated with that order, and another, which occurs independent of the order process The content of a document can be represented with one or more observation segments (OBX). Where headings or separations naturally exist within the text, it is preferred that each of these blocks be represented as a separate OBX record. Where systems are able to decompose the text into separate medical concepts, the most atomic level of granularity of content should be represented, ideally with each medical concept being represented in its own OBX segment. Many of these concepts can be represented as coded entities. MESSAGE RULES This message is used to transport electronic copies of following types Transcribed Reports: Value Description CD CN DS ED HP OP Cardiodiagnostics Consultation Discharge summary Emergency department report History and physical examination Operative report 2009 Government of Alberta Page 18 of 97

24 PN PR SP Procedure note Progress note Surgical pathology The following table describes the relationship between a TXA segments and an OBR segment for POS vendor translations. This translation can only occur from a MDM message to an ORU message. Seq. MDM Field Data Type Length Seq. OBR Field Data Type Length TXA Field Definition TXA-1 Set ID- TXA SI 4 OBR-1 Set ID - Observation Request SI 4 This field contains a number that uniquely identifies this transaction TXA-2 Document Type IS 2 OBR-4 Universal CE Service Identifier This field identifies the type of document (as defined in the transcription system). HL TXA-3 Document content presentation ID 2 No Mapping Required This is a conditional field, which is required whenever the message contains content as presented in one or more OBX segments. This field identifies the method by which this document was obtained or originated. HL TXA-4 Activity Date/Time TS 26 OBR-7 Observation Date/Time TS This field contains the date/time identified in the document as the date a procedure or activity was performed. This date can identify date of surgery, non-invasive procedure, consultation, examination, etc. TXA-5 Primary Activity Provider Code/Name XCN OBR Technician - name This field contains the name of the person identified in the document as being responsible for performing the procedure or activity. TXA-6 Origination Date/Time TS 26 OBR start date/time TS 26 This field contains the date and time the document was created (i.e., dictated, recorded, etc.). TXA-7 Transcription Date/Time TS 26 OBR Transcriptionist - Start date/time TS This field contains the date and time the input was actually transcribed. TXA-8 Not Supported This field contains the date and time the document was edited. TXA-9 Not Supported This field identifies the person who originated (i.e., dictated) the document. The document originator may differ from the person responsible for authenticating the document Government of Alberta Page 19 of 97

25 Seq. MDM Field Data Type TXA-10 Not Supported Length Seq. OBR Field Data Type Length TXA Field Definition This field identifies the person(s) responsible for authenticating the document, who may differ from the originator. Multiple persons may be responsible for authentication, especially in teaching facilities. This field is allowed to repeat an undefined number of times. TXA-11 Transcriptionist Code/Name XCN OBR Transcriptionist - name CN This field identifies the person responsible for transcribing the document. TXA-12 Unique Document Number EI 99 OBR-3 Filler Order Number EI 99 This field contains a unique document identification number assigned by the sending system. This document number is used to assist the receiving system in matching future updates to the document TXA-13 Parent Document Number EI 99 OBR parent's filler order number EI 99 This field contains a document number that identifies the parent document to which this document belongs. The parent document number can be used to assist the receiving system in matching future updates to this document. TXA-14 Not Supported This field is the placer application s order number. TXA-15 Not Supported This field is the order number associated with the filling application. Where a transcription service or similar organization creates the document and uses an internally unique identifier, that number should be inserted in this field. TXA-16 Unique Document File Name ST 60 OBR- 4.5 Universal Service Identifier - alternate text ST 60 This field contains a unique name assigned to a document by the sending system. The file name is used to assist the receiving system in matching future updates to the document. TXA-17 Document Completion Status ID 2 OBR- 25 Result Status ID 1 This field identifies the current completion state of the document. See chart below to map HL status to HL TXA-18 Not Supported ID 2 This is an optional field, which identifies the degree to which special confidentiality protection should be applied to this information Government of Alberta Page 20 of 97

26 Seq. MDM Field Data Type TXA-19 Not Supported Length Seq. OBR Field Data Type Length TXA Field Definition This is an optional field which identifies a document s availability for use in patient care. If an organization s business rules allow a document to be used for patient care before it is authenticated, the value of this field should be set to AV. If a document has been made available for patient care, it cannot be changed or deleted. If an erroneous document has been made available at any point in time and a replacement is not appropriate, then it may be marked as Canceled and removed, as in the case of a document being assigned to the wrong patient. Additional information must be provided via an addendum, which is separately authenticated and date/time stamped. If the content of a document whose status is Available must be revised, this is done by issuing a replacement, which is separately authenticated and date/time stamped. TXA-20 Not Supported This optional field identifies the storage status of the document. TXA-21 Not Supported This free text field (limited to 30 characters) contains the reason for document status change. TXA Authentication Person PPN OBR Principal Result Interpreter - name CN This field identifies the person responsible for authenticating the document. TXA Authentication Person - Date/time Action Performed TS OBR Principal Result TS Interpreter - Start date/time Date the report was authenticated. TXA-23 Distributed Copies (Code and Name of Recipients) XCN OBR- 28 Result Copies To XCN This field identifies the person(s) who are to receive copies of the report. The following chart maps the HL document completion status codes to the HL result status codes. HL70270 Document completion status HL0125 Result Status Code Name Code Name AU Authenticated F Final Result PA Pre-authenticated P Preliminary CA Cancelled X Cancelled 2009 Government of Alberta Page 21 of 97

27 TRANSACTION MESSAGES Send: MDM_T02 Response: None ERROR CONDITIONS NONE 2009 Government of Alberta Page 22 of 97

28 ORU_R01 MESSAGE PURPOSE This message is used to transport electronic copies of Diagnostic Imaging Text and Other Transcribed Reports from an RHA facility to the appropriate Physician Office System(s) (POS). The content of a document is represented within observation segments (OBX). Each OBX segment represents separate medical concepts. These concepts are represented as coded entities. MESSAGE RULES This message is used to transport electronic copies of following types Transcribed Reports: Value Description CD CN DS ED HP OP PN PR SP DI Cardiodiagnostics Consultation Discharge summary Emergency department report History and physical examination Operative report Procedure note Progress note Surgical pathology Diagnostic Imaging TRANSACTION MESSAGES Send: ORU_R01 Response: None ERROR CONDITIONS NONE 2009 Government of Alberta Page 23 of 97

29 TRANSACTION MESSAGE DETAIL SECTION GUIDE This section provides detailed specifications about a specific HL7 message or set of messages. It breaks down exactly where and how each piece of information will be conveyed, as well as restrictions on the content of the data including cardinality, table restrictions, length restrictions, etc. The structure uses a format adopted by the HL7 organization to document message profiles, and includes a detailed breakdown of the contents of each message into their constituent segment groups, segments, fields, components and sub-components. This specification is sufficient for an implementer to build a messaging interface. However, we strongly recommend joining the HL7 organization and obtaining a copy of the HL7 specifications. In particular, implementers should familiarize themselves with Chapter 2 of the relevant version of the HL7 standard, which provides detailed information about the structure of HL7 messages and such information as escape characters. CHARACTERISTICS This section contains information specific to the HL7 Conformance Profile format. The Identifier is a unique id assigned to the profile and is used in registering profiles in an HL7 repository. PROFILE TYPE Indicates what kind of profile is being displayed. The Encoding Method indicates what format of HL7 messages may be used. INTERACTIONS Each document will contain one or more interactions, with each interaction identifying a message, as well as the acknowledgment responsibilities associated with that message. MESSAGE CHARACTERISTICS This section discusses general properties associated with the message. Identifiers This section lists three types of identifiers; Message Profile Identifiers, Static Publish/Subscribe Identifiers Dynamic Publish/Subscribe Identifiers. Some applications may reference one or more of these identifiers. The Identifier is made up of the transaction number, an indication of whether the message is being sent from Regional Health Authorities to Physician Office Systems. The version number for the transaction in turn follows this. Transaction version numbers can be interpreted as follows: The number prior to the period is the major version number. A change in the major version number denotes a significant change in the operation of the transaction, and a break in compatibility with the prior version. The number following the period is the minor version number. The minor version number is incremented each time the functionality changes in a manner that is backward compatible with the previous version. The static and dynamic Publish/Subscribe Identifiers are HL7 fields intended for applications that use a publish/subscribe mechanism for routing. Dynamic Profile 2009 Government of Alberta Page 24 of 97