Order and result messages for pathology information systems

Transcription

1 Implementation guideline HL7 version 2.4 Order and result messages for pathology information systems PATHOLOGY, LABORATORY Date August 22, 2013 ID Author Heitmann Consulting and Services Dr. K.U. Heitmann Reviewers Nictiz Drs. T. van Stijn Nictiz Drs. C.E. Hülsmann

2 Index H-1 Introduction Original author Revision Review Translation Status Document history 5 H-2 Exchange format and workflow overview Version of the HL7 protocol Workflow overview 6 H-3 Order to the pathology laboratory Process Specification of message composition (segments) MSH segment PID segment PV1 segment ORC segment OBR segment SAC segment OBX segment 20 H-4 Order confirmation of receipt Variant Variant Variant MSA segment SAC segment 27 August 22, 2013 Order and result messages for pathology information systems

3 H-5 Pathology laboratory results Specification of message composition (segments) MSH segment PID segment PV1 segment ORC segment OBR segment OBX segment 38 H-6 Confirmation of receiving result message 41 H-7 Appendix I Communication MLLP U-DPS attributes concerning the HL7 connection 42 H-8 Appendix II Concepts 43 August 22, 2013 Order and result messages for pathology information systems

4 H-1 Introduction This document describes the HL7 version 2.4 messages used to order a study to be executed on tissue, cellular material or an autopsy on a non-living person. An order message is sent to the pathology laboratory. In addition, this document describes the result messages as a response to the described order messages. The document is based on earlier versions of two documents by Tieto Healthcare Netherlands BV: [1] Documentatie koppelingen U-DPS ZIS: HL7 ORU koppeling versie 2.4, document version 1.0, 24 December 2008 and [2] Documentatie HL7 koppelingen: ORM koppeling versie NL 2.4, document version 1.1.1, 24 November 2010 These documents as well as the current document are based on the following document that is owned bij the HL7 Netherlands Foundation: Implementatie Gids HL7 Versie 2.4 NL (Implementation guideline HL7 version 2.4 NL) In that document, the following chapters have mainly served as a source for the present document: [3] Chapter 2: Control [4] Chapter 3: Patient Administration [5] Chapter 4: Order Entry [6] Chapter 7: Observation Reporting 1.1. Original author Fons Geerts, Tieto Healthcare Netherlands BV 1.2. Revision Dr. K.U. Heitmann (Heitmann Consulting and Services) 1.3. Review Drs. T. van Stijn (Nictiz) Drs. C.E. Hülsman (Nictiz) 1.4. Translation This document has been translated from Dutch into English by Drs. C.E. Hülsmann. The purpose of translation is serving all software vendors that operate nationally and or internationally, developing software for the Dutch market Status Final August 22, 2013 Order and result messages for pathology information systems 4

5 1.6. Document history Version Date (ymd) Description Author Original document title: HL7 ORU koppeling versie 2.4 [1] Original document title: ORM koppeling versie NL 2.4 [2] Revision and merge of the first two ducuments, changes to version 2.4 and new message types/trigger events Addition of report number and sample number in the confirmation message and making LOINC codes compulsory where possible Addition to Specimen Source, adjustments made because of incoming comments More comments and clarifications from earlier versions, reporting protocol and ACK messages elaborated, correction of typing mistakes Fons Geerts Fons Geerts Dr. K. Heitmann Dr. K. Heitmann Dr. K. Heitmann Dr. K. Heitmann Correction of typing mistake OML event Dr. K. Heitmann Several changes after review by NICTIZ, mainly of semantic or syntactic nature Change of message type name ORU; addition of OBR-31 Reason for study Adjustment of Abstract Syntax Message for messages (addition of symbols) Dr. A. Huisman (MedicalPHIT for RIVM) Dr. K. Heitmann Dr. K. Heitmann Document review and lay-out change Drs. C.E. Hülsmann Addition of the SAC segment in OML^O21 after receiving vendor feedback February 8th Additional code for Reason for study, revision of the SAC segment, additional code for OBX-3 (additional note on material), examples Translation from Dutch into English, adjustment of note PID-3, update of par. 3.1: use of BSN is compulsory Dr. K. Heitmann Dr. K. Heitmann Drs. C.E. Hülsmann August 22, 2013 Order and result messages for pathology information systems 5

6 H-2 Exchange format and workflow overview 2.1. Version of the HL7 protocol U-DPS uses the HL7 protocol version 2.4 NL. The BSN is the Dutch national identification number called Burgerservicenummer, also used in the healthcare sector to identify a person. Whether or not this BSN has to be delivered to the receiving oranizations, depends on the urge of the representatives of these organizations. In most cases, these organizations are Hospitals, the receiver of the messages being the Hospital Information System (HIS). The HL7 Netherlands Foundation has served as the main advisor for the specifications in this document. However, this foundation does not own any specific guidelines on the composition of an order message for a pathology laboratory. For this reason, this document emphasizes the use of the OBX segment as part of the message as far as the Kind of material and Clinical information is concerned Workflow overview Diagram 1 is an overview of all involved actors (application roles) and the HL7 v2.4 messages that are involved. Diagram 1: Interactions between a lab order placer (original order initiator) and lab order filler (original order executor, in this case the pathology laboratory) August 22, 2013 Order and result messages for pathology information systems 6

7 A requesting system (order placer) sends requests for studies (orders) on tissue, cellular material or an autopsy on a non-living person to the pathology laboratory (order filler) by sending a Lab Order Message OML^O21 (Message Type OML, Trigger event O21). After receiving the request, the pathology laboratory can reply by sending a Lab Order Response ORL^O22 (asynchronous). The pathology laboratory can send the study result using an Unsolicited Laboratory Observation Message ORU^R01. In order to confirm the receipt of the study results, the order placer then sends an acknowledgement message (ACK^R01) (synchronous). In the following chapters the composition of the mentioned messages will be further elaborated as well as the segments that are used in this document. Note: The Lab Order Message OML^O21 is a new message since version 2.4 and replaces the old ORM message. It is merely the same as the OMG message with some extensions. August 22, 2013 Order and result messages for pathology information systems 7

8 H-3 Order to the pathology laboratory In order to support the requests for study of tissue, cellular material or executing an autopsy on a non-living person that are sent to the pathology laboratory, U-DPS supports a system for electronic ordering. This system is using the HL7 protocol. From now on in this document the U-DPS system is mentioned when referring to the system that receives the order (order filler), where this can also be another information system at the pathology department Process The order placer, e.g. an HIS, sends an order and U-DPS confirms receiving the order by sending a return message. The laboratory can already inform the order placer about the study report number and the sample number in this return message. However, in this stage informing the order placer about these numbers is optional. The study is executed at the pathology laboratory, and after that, when closing it, the order placer is informed about the study results and the order number. Placing the order is done by an authorized healthcare provider (HCP) and has to be interpreted as an official order to perform a study. The code and name of the requesting HCP are used in the pathology study report. Also, the order message is a source for patient information concerning his name and address, a description of the material type and clinical information, that is available in the study result report. Use of the BSN in digital communication in healthcare is compulsory. For this reason, using the 2.4 version of this protocol is a necessity Specification of message compostion (segments) The Lab Order Message OML^O21 uses the following HL7 v2.4 segments: Segment MSH PID PV1 { } ORC [ ] OBR Description Message header Patient identification Patient visit Order communication Observation Request [ { SAC } ] Specimen Container Details [ { OBX } ] Observation/Result (Legend: Abstract Message Syntax, [ ] optional, { } one or more recurrences) August 22, 2013 Order and result messages for pathology information systems 8

9 3.3. MSH segment Table 1: HL7 Attribute Table - MSH - Message Header SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 1 ST R Field Separator 2 4 ST R Encoding Characters ^~& HD O Sending Application Contents agreed on by all parties concerned HD O Sending Facility Contents agreed on by all parties concerned HD O Receiving Application Contents agreed on by all parties concerned HD O Receiving Facility Contents agreed on by all parties concerned 7 26 TS R Date/Time Of Message Format: YYYYMMDDhhmmss 8 40 ST O Security 9 13 CM R 0076/ Message Type OML^O21 note MSH ST R Message Control ID 11 3 PT R Processing ID P VID R Version ID NM O Sequence Number ST O Continuation Pointer 15 2 ID O Accept Acknowledgment Type 16 2 ID O Application Acknowledgment Type 17 3 ID O Country Code ID O Y Character Set CE O Principal Language Of Message ID O Alternate Character Set Handling Scheme ID O Y Conformance Statement ID Note MSH9: Element 9 in the MSH segment (Message type), in short MSH-9, has the following value: OML^O21. In the response message Lab Order Response ORL^O22 (see chapter H-5 in this document) the value is: ORL^O22. And so on PID segment Table 2: HL7 Attribute Table PID Patient identification SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 4 SI O Set ID - PID 2 20 CX B Patient ID August 22, 2013 Order and result messages for pathology information systems 9

10 3 250 CX R Y Patient Identifier List Patient number note PID CX B Y Alternate Patient ID - PID XPN R Y Patient Name Patient name note PID XPN O Y Mother s Maiden Name 7 26 TS O Date/Time of Birth Date of birth 8 1 IS O Administrative Sex Gender XPN B Y Patient Alias CE O Y Race XAD O Y Patient Address Patient address information note PID IS B County Code XTN O Y Phone Number - Home XTN O Y Phone Number - Business CE O Primary Language CE O Marital Status CE O Religion CX O Patient Account Number ST B SSN Number - Patient DLN O Driver's License Number - Patient CX O Y Mother's Identifier CE O Y Ethnic Group ST O Birth Place 24 1 ID O Multiple Birth Indicator 25 2 NM O Birth Order CE O Y Citizenship CE O Veterans Military Status CE B Nationality TS O Patient Death Date and Time 30 1 ID O Patient Death Indicator 31 1 ID O Identity Unknown Indicator IS O Y Identity Reliability Code TS O Last Update Date/Time HD O Last Update Facility CE C Species Code CE C Breed Code ST O Strain CE O Production Class Code Note PID3: Patient identifier list (PID-3) Only the ADT message HL7 v2.4 has the possibility to include the BSN, in a recurring PID-03 (sub-)segment, e.g.: August 22, 2013 Order and result messages for pathology information systems 10

11 PID ^^^LOCAL^PI ~ ^^^NLMINBIZA^NNNLD Onwel^Jolanda... The first sub sub segment is the local patient number, the second is the BSN. Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ < assigning authority (HD)> ^ <identifier type code (ID)> ^ < assigning facility (HD) ^ <effective date (DT)> ^ <expiration date (DT)> Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)> Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)> Examples BSN ^^^NLMINBIZA^NNNLD^^ Official identity document (passport/identity card) AA ^^^NLMINBIZA^PPN^^ Driver s license ^^^NLRDW^DL^^ Immigration document ^^^NLIND^CZ^^ When using the BSN and the official identity document, stating the date of verification can be necessary. The effective date component can be used to do so. Attention: The formal meaning of effective date is the starting date of the identifier, meaning that from that moment on the identifier is valid. In this case the component effective date is given a different meaning. Table 3: User-defined Table Assigning Authority Code Description Dutch application NLMINBIZA NLMINJUS NLVWS NLIND NLRDW CIBG Prismant Vektis NL Ministerie van Binnenlandse Zaken (Ministry of Internal Affairs) NL Ministerie van Justitie (Ministry of Justice) NL Ministerie van Volksgezondheid, Welzijn en Sport (Ministry of Health, Wellbeing and Sports) NL Immigratie en Naturalisatie Dienst (Immigration Services) NL Rijksdienst voor het Wegverkeer (National road traffic service) NL Centraal Informatiepunt Beroepen Gezondheidszorg (Dutch Central Information office for Healthcare professions) NL Onder andere voor de Landelijke Medische Registratie (LMR) (a.o. for national medical registration) NL Centrum voor informatie en standaardisatie voor de zorgverzekeraars Burgerservicenummer (BSN) Reisdocument (paspoort/identiteitskaart) (BSN, passport/official identity document) Vreemdelingendocument (Immigration document) Rijbewijs (Driver s license) Zorgverlener Identificatienummer UZI (Unique Healthcare Provider Identification number) August 22, 2013 Order and result messages for pathology information systems 11

12 LOCAL <AGB code> (Centre for information and standardization for healthcare insurance companies) Lokaal gedefinieerd (Locally defined) AGB code van de instelling die het patiëntnummer heeft uitgereikt (AGB code of the organization that issued the patient number) Compulsory in case of exchange of healthcare information across institution borders Table 4: HL7 Table Identifier type Code Description Dutch application AM American Express AN Account number DBC identification number BA Bank Account Number To be used for a giro or bank account number. The concerned bank has to be mentioned in the field Assigning Authority. Attention: this was BANK and GIRO in IG 2.3. BR BRN Birth registry number Breed Registry Number CZ Citizenship Card Immigration document as meant by the Dutch identification law WID (Wet op de identificatieplicht) DI Diner s Club card DL Driver s license number e.g. concerning the Dutch identification law WID ( Wet op de identificatieplicht ) DN Doctor number DR Donor Registration Number The Dutch Donorregistratienummer is meant. DS EI EN FI GI GN Discover Card Employee number Employer number Facility ID Guarantor internal identifier Guarantor external identifier HC Health Card Number The Dutch Zorgpasnummer is meant. JHN LN LR MA MC MCN Jurisdictional health number (Canada) License number Local Registry ID Medicaid number Medicare number Microchip Number MR Medical record number Dutch Medisch dossiernummer is meant MS NE NH NI MasterCard National employer identifier National Health Plan Identifier National unique individual identifier NNNLD National Person Identifier where the xxx is the ISO table character (alphabetic) country code NNNLD BSN August 22, 2013 Order and result messages for pathology information systems 12

13 NPI National provider identifier The Dutch UZI number PEN Pension Number PI Patient internal identifier Patient number within the organization PN Person number PPN Passport number Passport number, but also in general an official identity document (e.g. in accordance with the Dutch identification law WID: Wet op de identificatieplicht PRN Provider number PT Patient external identifier To be used for e.g. regional patient number, or the patient number in another healthcare institution. RR RRI SL SR SS U UPIN VN VS WC WCN XX Railroad Retirement number Regional registry ID State license State registry ID Social Security number Unspecified Medicare/HCFA s Universal Physician Identification numbers Visit number VISA WIC identifier Workers Comp Number Organization identifier Note PID5: Components: In Version 2.3, replaces the PN data type. <family name (FN)> ^ <given name (ST)> ^ <second and further given names or initials thereof (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (IS)> ^ <name type code (ID) > ^ <name representation code (ID)> ^ <name context (CE)> ^ <name validity range (DR)> ^ <name assembly order (ID)> U-DPS: < second and further given names or initials thereof> contains the Dutch voorletters (initials) Subcomponents of family name: <surname (ST)> & <own surname prefix (ST)> & <own surname (ST)> & <surname prefix from partner/spouse (ST)> & <surname from partner/spouse (ST)> U-DPS: naamvrouw = <own surname> naamman (echtgenoot van) = <surname from partner/spouse> In HL7 version 2.3 the field PID-9 Patient alias was still used to communicate several different parts of the name. In this version however, the datatype XPN is extensive enough to communicate all parts of the Legal name. Note PID11: Components: In Version 2.3 and later, replaces the AD data type. <street August 22, 2013 Order and result messages for pathology information systems 13

14 address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code (ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)> ^ <county/parish code (IS)> ^ <census tract (IS)> ^ <address representation code (ID)> ^ <address validity range (DR)> Subcomponents of street address: <street address (ST)> & <street name (ST)> & <dwelling number (ST)> This field contains all the patient s addresses. The first address in this field has to be the address that is used to correspond with the patient. The field is filled as specified in Table 5. U-DPS does not use all the data in this element. Table 5: HL7 Adress Type componenten en sub-componenten Component Sub component Usage in The Netherlands Street address As of version 2.4 street address is a complex datatype. Different parts of the address can be filled in into the various sub components. Street address Street name Dwelling number Street name and dwelling number should be in this field as a composition, for reasons of backwards compatibility. Straatnaam Huisnummer, some implementations are known where dwelling number and street name are combined in the field Street name. Other designation City State Zip or postal code Country Address type Other geographic designation County/parish code Census tract Address representation code Address validity range Huisnummertoevoeging, additional information to specify the precise dwelling. Woonplaats N.A. Postcode, in case of a Dutch postal code no spaces should be entered: e.g. 2316XA Country in which the specified address is. The first address should have the value M (mailing). Other addresses can be specified, e.g. home address ( H ), or temporary address or residence ( C ). N.A. N.A. N.A. N.A. Starting date and end date of validity of the address can be specified using this field. This could be of use for temporary addresses. Date range start date/time Date range end date/time Starting date of validity of the address Last moment in time when the address is still valid (valid up to and including). Examples: PID ^^^^PI~ ^^^^NNNLD Reubsaet- Geurts&""&Geurts&""&Reubsaet^A^^^^^L F Aelserhof 1^^Elsloo Lb^^6181 LB^NL P N "" N PID ^^^^PI~ ^^^^NNNLD Broek van der Gruiter de&de&gruiter&van der&broek^l.^^^^^l V Postweg August 22, 2013 Order and result messages for pathology information systems 14

15 14&Postweg&14^^Tilburg^^5000KL^^M^^^^^ & ~Logeerstraat 34&Logeerstraat&34^^Best^^7800YY^^C^^^^^ & N 3.5. PV1 segment Table 6: HL7 Attribute Table - PV1 Patient visit SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 4 SI O Set ID - PV1 2 1 IS R Patient Class Indication meaning inpatient or outpatient values: see Table PL O Assigned Patient Location Department 4 2 IS O Admission Type CX O Preadmit Number 6 80 PL O Prior Patient Location XCN O Y Attending Doctor XCN O Y Referring Doctor XCN B Y Consulting Doctor 10 3 IS O Hospital Service PL O Temporary Location 12 2 IS O Preadmit Test Indicator 13 2 IS O Re-admission Indicator 14 6 CWE O Admit Source 15 2 IS O Y Ambulatory Status 16 2 IS O VIP Indicator XCN O Y Admitting Doctor 18 2 IS O Patient Type CX O Visit Number Case of illness, in case this is used by the HIS (SAP) FC O Y Financial Class Financial Class 21 2 IS O Charge Price Indicator Charge Price Indicator 22 2 IS O Courtesy Code Courtesy Code 23 2 IS O Credit Rating Credit Rating 24 2 IS O Y Contract Code Contract Code 25 8 DT O Y Contract Effective Date Contract Effective Date NM O Y Contract Amount Contract Amount 27 3 NM O Y Contract Period Contract Period 28 2 IS O Interest Code Interest Code 29 1 IS O Transfer to Bad Debt Code 30 8 DT O Transfer to Bad Debt Date Transfer to Bad Debt Code Transfer to Bad Debt Date IS O Bad Debt Agency Code Bad Debt Agency Code NM O Bad Debt Transfer Amount NM O Bad Debt Recovery Amount Bad Debt Transfer Amount Bad Debt Recovery Amount August 22, 2013 Order and result messages for pathology information systems 15

16 34 1 IS O Delete Account Indicator Delete Account Indicator 35 8 DT O Delete Account Date Delete Account Date 36 3 IS O Discharge Disposition Discharge Disposition CM O Discharged to Location Discharged to Location CE O Diet Type Diet Type 39 2 IS O Servicing Facility Servicing Facility 40 1 IS B Bed Status Bed Status 41 2 IS O Account Status Account Status PL O Pending Location Pending Location PL O Prior Temporary Location Prior Temporary Location TS O Admit Date/Time Admit Date/Time TS O Y Discharge Date/Time Discharge Date/Time NM O Current Patient Balance Current Patient Balance NM O Total Charges Total Charges NM O Total Adjustments Total Adjustments NM O Total Payments Total Payments CX O Alternate Visit ID Alternate Visit ID 51 1 IS O Visit Indicator Visit Indicator XCN B Y Other Healthcare Provider Other Healthcare Provider Table 7: possible values for PV1-2 Code Beschrijving I O P K D B klinisch (inpatient) Poliklinisch (outpatient) Preadmit (Preadmit) MedKeuring (medical test) Dag (day) PolBev (Obstetrics) 3.6. ORC segment Table 8: HL7 Attribute Table ORC Common Order SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 2 ID R N Order Control Order status note ORC EI C Placer Order Number Placer order number, delivered by the sending system 3 22 EI C Filler Order Number Filler order number, PA number note ORC EI O Placer Group Number August 22, 2013 Order and result messages for pathology information systems 16

17 5 2 ID O N Order Status 6 1 ID O Response Flag TQ O Y Quantity/Timing Used to specify the priority note ORC CM O Parent 9 26 TS O Date/Time of Transaction Date/time when the order is registered in the ordering system. note ORC XCN O Y Entered By XCN O Y Verified By XCN O Y Ordering Provider Ordering Provider (coded) note ORC PL O Enterer s Location Location (coded) note ORC XTN O Y/ Call Back Phone Number TS O Order Effective Date/Time CE O Order Control Code Reason CE O Entering Organization CE O Entering Device XCN O Y Action By CE O Advanced Beneficiary Notice Code XON O Y Ordering Facility Name XAD O Y Ordering Facility Address XTN O Y Ordering Facility Phone Number XAD O Y Ordering Provider Address CWE O N Order Status Modifier Note ORC1: Of all available codes that can be delivered using this element, U-DPS uses the codes: NW, CA and CR. Table 9: possible values for ORC-1 Code Description NW CA or CR nieuwe order (new order) verwijderen order (cancel order) Cancelling the order can currently only be indicated if the order has not yet been incorporated into a report. August 22, 2013 Order and result messages for pathology information systems 17

18 Note ORC3: The filler order number ( rapportnummer ) will be the unique laboratory order number indicating the registered study. The used format is: <type of study><year> <serial number> type of study can contain: B, C, S, T or M. Year: only the last two digits of the year in which the material is received. Serial number: a pathology/anatomy (PA) number (unique for each laboratory) and possibly a version indicator: A, B, C, D... Examples: T Histologie C Cytologie S Obductie B Cervixcytologie This study report number is only issued when the received order is being processed. This can be at the moment of confirming the order (when processing the order starts), or later, when the report after performing the study is finished. Note ORC7: ORC-7 sub field 6 can contain a character that may cause the priority of the study to be risen. In other words: should the study be performed in emergency, or should it not. U-DPS reacts on the character S. Caused by this S, the field soortaanvraag (kind of order) will contain the value spoed (emergency). All other values lead to a normal priority: normaal. The information is also part of the OBR-27 sub field 6. Note ORC9: Date-time on which the order is entered into the ordering system of the ordering application. Should this field be empty, then the date of de MSH segment can be used as a source. Note ORC12: The ordering provider number that is delivered by the HIS, is converted into an order placer code in U-DPS. When a result is issued, the ordering provider number as known in the HIS will be provided by U-DPS. Note ORC13: In case registering a location code is a necessity, the code will be incorporated into the U-DPS report OBR segment Table 10: HL7 Attribute Table OBR Observation Request SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 4 SI O Set ID - OBR 2 22 EI C Placer Order Number Placer order number, delivered by the sending August 22, 2013 Order and result messages for pathology information systems 18

19 system 3 22 EI C Filler Order Number + Filler order number, PA number CE R Universal Service ID Type of study note OBR4 5 2 ID B Priority - OBR 6 26 TS B Requested Date/Time 7 26 TS C Observation Date/Time # 8 26 TS O Observation End Date/Time # 9 20 CQ O Collection Volume * XCN O Y Collector Identifier * 11 1 ID O Specimen Action Code * CE O Danger Code ST O Relevant Clinical Info TS C Specimen Received Date/Time * CM O Specimen Source * XCN O Y Ordering Provider See ORC segment XTN O Y/ Order Callback Phone Number ST O Placer Field ST O Placer Field ST O Filler Field ST O Filler Field TS C Results Rpt/Status Chng - Date/Time CM O Charge to Practice ID O Diagnostic Serv Sect ID Hospital/institution optional: location of requestor (coded) 25 1 ID C Result Status CM O Parent Result TQ O Y Quantity/Timing XCN O Y/ Result Copies To Receivers of copies of the result report CM O Parent ID O Transportation Mode (code and name to be filled in) CE O Y Reason for Study note OBR CM O Principal Result Interpreter CM O Y Assistant Result Interpreter CM O Y Technician CM O Y Transcriptionist TS O Scheduled Date/Time + August 22, 2013 Order and result messages for pathology information systems 19

20 37 4 NM O Number of Sample Containers * CE O Y Transport Logistics of Collected Sample * CE O Y Collector s Comment * CE O Transport Arrangement Responsibility ID O Transport Arranged 42 1 ID O Escort Required CE O Y Planned Patient Transport Comment CE O Procedure Code CE O Y Procedure Code Modifier CE O Y Placer Supplemental Service Information CE O Y Filler Supplemental Service Information Note OBR4: The sending system can use this field for terms like one of the following: Histologie (Histology) Cytologie (Cytology) Obductie (Autopsy) Cervixcytologie (Cervixcytology) In practice, the pathology department will often decide by itself on the study to be performed. Note OBR31: The reason for study (request) can be specified here. This is optional. For now only one of the following values is permitted: 3.8. SAC segment BVO-DDK (bowel cancer screening) BVO-DDK-NOTP (bowel cancer screening, only for study, it is not permitted to redistribute the information to third parties, e.g. ColonIS) SAC segment specification see paragraph OBX segment Table 11: HL7 Attribute Table OBX Observation SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 4 SI O Set ID - OBX Serial number of the OBX segment 2 2 ID C Value Type FT CE R Observation Identifier note OBX ST C Observation Sub-ID August 22, 2013 Order and result messages for pathology information systems 20

21 * C Y Observation Value note OBX CE O Units 7 60 ST O References Range 8 5 IS O Y/ Abnormal Flags 9 5 NM O Probability 10 2 ID O Y Nature of Abnormal Test 11 1 ID R Observation Result Status TS O Date Last Observation Normal Value ST O User Defined Access Checks TS O Date/Time of the Observation CE O Producer's ID XCN O Y Responsible Observer CE O Y Observation Method EI O Y Equipment Instance Identifier TS O Date/Time of the Analysis The clinical data is available as normal text in U-DPS. For this reason, it speaks for itself to use the OBX segment in the order message for this information exchange. The OBX segment can provide big chunks of formatted text, that can be processed by U-DPS. Note OBX3: One or more OBX segment will be used in the OBX-3 field. U-DPS is expecting the information as specified in Table 12. Table 12: possible values for OBX-3 Code U-DPS rubriek (section) Permitted values KLINGEG VRAAG MAT MATTOE TOESTEMMING klinische gegevens, vrije tekst (clinical data, free text) klinische vraagstelling, vrije tekst (clinical request, free text) aard materiaal, afgestemd op de inhoud van de keuzelijst: aard materiaal in U-DPS (kind of material, in harmony with the contents of the list of choices called aard materiaal (kind of material) in U-DPS) aanvullende opmerkingen op het materiaal (additional notes about the material) Toestemmingcipa, de toestemming om uitslagen door te sturen naar de landelijke PALGA databank (die voorheen cipa heette) (Permission cipa to send the results to the national PALGA data bank, formerly called cipa ) ja (yes) beperkt (restricted) wetenschap (research) nee (no) RESTMATERIAAL Restmateriaal ja (yes) August 22, 2013 Order and result messages for pathology information systems 21

22 Een term die begint met CR_ (a term starting with CR_) Een andere term die niet in dit rijtje voorkomt (A different term, not stated in this list) (Rest material) verkrijgingswijze (method used to acquire the substance) cris3 cervixcytologie (cris3 cervixcytology) (could be used as an indicatior for a code) nee (no) lokaal (local) vernietigen (destroy) For this, the SAC segment SAC-6 is used, see par. 4.5 See also the note below Note OBX5: OBX-5 is used for text belonging to the concerned identifier. The amount of text is almost unlimited, which makes this element very suitable for communicating study requests and their corresponding results as to be performed by pathology laboratories. Tissue and cell studies The clinical information for these types of research is stated in free text. The types of study distinguished in pathology are: histology, cytology and autopsy. The material kind is restricted. U-DPS uses a choice list called aardmateriaal (kind of material). The information provided by the HIS need to meet the information that is available in the following list: OBX-3 = MAT indicates to U-DPS that the concerned information is kind of material. OBX-3 = VERKRIJGING : the method used to acquire the substance is stated in SAC-6, see the SAC segment in par OBX-3 = KLINGEG and VRAAG are indicators for other clinical data. Information is acquired from the sections klinische gegevens (clinical data) and klinische vraagstelling (clinical question) respectively. Cervixcytology protocol CRIS3 Should the code indicate a value that has been determined as part of the protocol, then a numeric code is sufficient. Should the code indicate free text, then a restiction of 24 positions needs to be regarded. Apart from the coded clinical data as part of the CRIS3 protocol, it is possible to extend the clinical information with free text. OBX-3 KLINGEG and VRAAG are an indication for this extended clinical information being present. Information is acquired from the sections klinische gegevens and klinische vraagstelling respectively. One or more OBX segments will be used. U-DPS expects the information in the OBX-3 field as specified in Table 12. Should the code begin with CR_, then values as stated in Table 13 are expected. Note: all codes are defined locally. This means that they have to contain L (see examples) as namespace identifier. August 22, 2013 Order and result messages for pathology information systems 22

23 Table 13: possible values for CR_ terms in OBX-3 CR_ term values allowed format/ clarification CR_DATUMSTRIJK CR_AANLEIDING 1 BVO 2 BVO-herh. (wegens onbeoordeelbaarheid) 3 (gyn.) klacht/sympt. 4 vervolgonderzoek 5 DES-dochter 6 op verzoek vrouw 9 anders: (vrije tekst maximaal 24 tekens). CR_DOOR 1 Huisarts 2 Gynaecoloog 3 Assistent(e) 9 anders: (vrije tekst maximaal 24 tekens). CR_INSTRUMENT 1 cervexbrush 2 cytobrush en spatel 3 spatel 4 dunne laag 9 anders: (vrije tekst maximaal 24 tekens). CR_KLACHTEN 0 geen 1 abnormaal bloedverlies 2 contactbloedingen 9 anders: (vrije tekst maximaal 24 tekens). CR_DATUMLM dd-mm-yy 1. (bowel screening 2. bowel screening recurrence, because of diffculties of evaluation 3. Gynaecological complaint/symptom 4. Further examination 5. DES daughter 6. On women s request 9. Other: (free text, max. 24 characters) ) 1. (General Practitioner 2. Gynaecolgist 3. Assistant 9. Other: (free text, max. 24 characters) ) 1. (Cervexbrush 2. Cytobrush and spatula 3. Spatula 4. Thin layer 9. Other: (free text, max. 24 characters) ) 0. (None 1. Abnormal blood loss 2. Contact bleedings 9. Other: (free text, max. 24 characters) ) dd-mm-yy CR_PATROON 0 geen 1 regelmatig 2 onregelmatig 3 menopauze 4 postmenopauze 9 anders: (vrije tekst maximaal 24 tekens). X onbekend CR_ANTICONCEPTIE 0 geen 1 hormonaal 2 IUD 0 (none 1 regular 2 irregular 3 menopause 4 post menopauze 9 other: (free text, max. 24 characters) X unknown) 0 (none 1 hormonal 2 IUD 9 other: (free text, max. August 22, 2013 Order and result messages for pathology information systems 23

24 CR_HORMOONGEBRUIK 0 geen CR_OPMERKING 0 geen CR_INGREPEN 0 geen 9 anders: (vrije tekst maximaal 24 tekens). X onbekend 1 > (vrije tekst; naam preparaat maximaal 24 tekens). X onbekend 1 wel: (vrije tekst, maximaal 24 tekens). 1 cryo-, coagulatie- of laserbehandeling 2 conisatie, lisexcisie, biopt 3 supravaginale uterusextirpatie 5 radiotherapie 6 combinatie, nl: > (vrije tekst, maximaal 24 tekens). 9 anders: > (vrije tekst, maximaal 24 tekens). X onbekend N n.v.t CR_ASPECT 1 normaal 2 niet gezien 3 abnormale/verdachte portio N n.v.t CR_ZWANGERSCHAP 0 geen CR_DUUR 1 zwangerschap 2 post partum 3 lactatie 4 postlactatie 5 geen lactatie X onbekend N n.v.t 24 characters) X unknown) 0 (none 1 > (free text; name supplement max. 24 characters) X unknown) 0 (no remark 1 remark: (free text; name supplement max. 24 characters) ) 0 (none 1 cryo, coagulation or laser treatment 2 conisation, lisexcision, biopsy 3 supravaginal uterus extirpation 5 radiotherapy 6 combination, namely: > (free text; name supplement max. 24 characters) 9 other: (free text, max. 24 characters) X unknown N N.A.) 1 (normal 2 not seen 3 abnormal/suspicious portio N N.A.) 0 (none 1 pregnancy 2 post partum 3 lactation 4 post lactation 5 no lactation X unknown N N.A.) number in weeks CR_BVOREGNR For the purpose of cervical cancer screening. This mainly concerns requests for screening studies by gynaecologists. The screening registration number is issued by the screening organization sending the calls for screening. This is a 14-digit number, the first four digits correspond to the screening organization. General example fragment OBX 1 FT MAT^^L darm F August 22, 2013 Order and result messages for pathology information systems 24

25 OBX 2 FT KLINGEG^^L This is the space for free text concerning clinical information.\.br\next line F OBX 3 FT VRAAG^^L Maligniteit? F Example fragment specifically for cervix cytology OBX 1 FT CR_DATUMSTRIJK^^L F OBX 2 FT CR_AANLEIDING^^L 1 F OBX 3 FT CR_DOOR^^L 1 F OBX 4 FT CR_INSTRUMENT^^L 1 F OBX 5 FT CR_KLACHTEN^^L 9 erosie F OBX 6 FT CR_DATUMLM^^L F OBX 7 FT CR_PATROON^^L F OBX 8 FT CR_ANTICONCEPTIE^^L 0 F OBX 9 FT CR_HORMOONGEBRUIK^^L 0 F OBX 10 FT CR_OPMERKINGEN^^L 1 free text F OBX 11 FT CR_INGREPEN^^L 0 F OBX 12 FT CR_ASPECT^^L 1 F OBX 13 FT CR_ZWANGERSCHAP^^L 1 F OBX 14 FT CR_DUUR^^L 20 F OBX 15 FT KLINGEG^^L Extra clinical information F Example fragment specifically for polyp coecum OBX 10 FT MAT^^L coecum O OBX 11 FT VRAAG^^L Maligniteit? O OBX 12 FT VERKRIJGING^^L biopteur O OBX 13 FT MATTOE^^L Poliep 1: Afgebeeld coecum 5 mm gesteeld (Paris classif. 0-1p) Adenocarcinoom Kudo 1 resectietechniek; niet radicaal; potje I O August 22, 2013 Order and result messages for pathology information systems 25

26 H-4 Order confirmation of receipt After receiving the order request, the pathology laboratory responds using the Lab Order Response ORL^O22. The confirmation of receipt as specified in this document contains the following HL7 v2.4 segments: Segment MSH MSA Beschrijving Message header Message acknowledgement [ (beginning of optional group) PID Patient Identification { (beginning of group, recurring if necessary) ORC OBR Common Order Observation Request [ { SAC } ] Specimen Container Details (optional, recurring if necessary) } (end of group, recurring if necessary) ] (end of optional group) Basically there are three variants of the confirmation message, depending on what has to be communicated to the other party Variant 1 The confirmation message sent by U-DPS, containing an MSH (see above) and an MSA segment. This is the most simple way to send a confirmation message Variant 2 In case of having to send the segments as mentioned in Variant 1, including a report number, the optional group containing the PID, ORC and OBR is used. The report number can be found in the ORC-3 element (filler order number, see the specification of the ORC segment par. 3.6). Note that also the PID segment containing the patient data and the OBR segment containing the request data have to be added Variant 3 The SAC segment (can be recurring) can be used to communicate a sample number, should the sample numbers also need to be added to the message. August 22, 2013 Order and result messages for pathology information systems 26

27 4.4. MSA segment Table 14: HL7 Attribute Table - MSA - Message Acknowledgment SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 2 ID R Acknowledgment Code AA = correct 2 20 ST R Message Control ID 3 80 ST O Text Message 4 15 NM O Expected Sequence Number 5 1 ID B Delayed Acknowledgment Type CE O Error Condition AE = incorrect 4.5. SAC segment Table 15: HL7 Attribute Table - SAC - Specimen and container detail segment SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 80 EI O External Accession Identifier note SAC EI O Accession Identifier 3 80 EI C Container Identifier note SAC EI C Primary (parent) Container Identifier 5 80 EI O Equipment Container Identifier SPS O Specimen Source note SAC6 (rest van het segment) Note SAC1: This identifier contains (if the segment is present) the sample number, in the way it has been issued (in advance) by the order placer. The identifier can also contain identifying sample characteristics (e.g. Roman digits to indicate a jar number) Examples: Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ SAC ^OLP SAC IV^MDLS <universal ID (ST)> ^ <universal ID type (ID)> Note SAC3: This identifier contains the sample number as issued by the laboratory. Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)> Example: SAC ^LMS August 22, 2013 Order and result messages for pathology information systems 27

28 Note SAC6: A value of the HL7 table 0070 (specimen source) needs to be used here. Components: <specimen source name or code (CE)> ^ <additives (TX)> ^ <free text (TX)> ^ <body site (CE)> ^ <site modifier (CE)> ^ <collection method modifier code (CE)> ^ <specimen role (CE)> Example: SAC ^LMS ASP Table 16: possible values for Specimen Source (HL7 table 0070) Code ABS AMN ASP BBL BDY BIFL BLD BLDA BLDC BLDCO BLDV BON BPH BPU BRN BRO BRTH CALC CBLD CDM CNJT CNL COL CSF CTP CUR CVM CVX CYST DIAF Description Abscess Amniotic fluid Aspirate Blood bag Whole body Bile fluid Whole blood Blood arterial Blood capillary Cord blood Blood venous Bone Basophils Blood product unit Burn Bronchial Breath (use EXHLD) Calculus (=Stone) Cord blood Cardiac muscle Conjunctiva Cannula Colostrum Cerebral spinal fluid Catheter tip Curettage Cervical mucus Cervix Cyst Dialysis fluid August 22, 2013 Order and result messages for pathology information systems 28

29 DOSE DRN DUFL EAR EARW ELT ENDC ENDM EOS EXG EXHLD EYE FIB FIST FLT FLU GAS GAST GEN GENC GENL GENV HAR IHG ISLT IT LAM LIQ LN LNA LNV LYM MAC MAR MBLD MEC MILK MLK NAIL NOS ORH PAFL Dose med or substance Drain Duodenal fluid Ear Ear wax (cerumen) Electrode Endocardium Endometrium Eosinophils Exhaled gas (=breath) Exhaled gas (=breath) Eye Fibroblasts Fistula Filter Body fluid, unsp Gas Gastric fluid/contents Genital Genital cervix Genital lochia Genital vaginal Hair Inhaled Gas Isolate Intubation tube Lamella Liquid NOS Line Line arterial Line venous Lymphocytes Macrophages Marrow Menstrual blood Meconium Breast milk Milk Nail Nose (nasal passage) Other Pancreatic fluid August 22, 2013 Order and result messages for pathology information systems 29

30 PAT PLAS PLB PLC PLR PMN PPP PRP PRT PUS RBC RT SAL SEM SER SKM SKN SMN SNV SPRM SPT SPTC SPTT STL STON SWT TEAR THRB THRT TISG TISPL TISS TISU TLGI TLNG TSMI TUB ULC UMB UMED UR URC Patiënt Plasma Plasma bag Placenta Pleural fluid (thoracentesis fld) Polymorphonuclear neutrophils Platelet poor plasma Platelet rich plasma Peritoneal fluid /ascites Pus Erythrocytes Route of medicine Saliva Seminal fluid Serum Skeletal muscle Skin Seminal fluid Synovial fluid (Joint fluid) Spermatozoa Sputum Sputum - coughed Sputum - tracheal aspirate Stool = Fecal Stone (use CALC) Sweat Tears Thrombocyte (platelet) Throat Tissue gall bladder Tissue placenta Tissue Tissue ulcer Tissue large intestine Tissue lung Tissue small intestine Tube NOS Ulcer Umbilical blood Unknown medicine Urine Urine clean catch August 22, 2013 Order and result messages for pathology information systems 30

31 URNS URT URTH USUB VITF VOM WAT WBC WICK WND WNDA WNDD WNDE Urine sediment Urine catheter Urethra Unknown substance Vitreous Fluid Vomitus Water Leukocytes Wick Wound Wound abscess Wound drainage Wound exudate August 22, 2013 Order and result messages for pathology information systems 31

32 H-5 Pathology laboratory results The pathology laboratory result is sent as an Unsolicited Laboratory Observation Message ORU^R01. In case of U-DPS, the concerned studies are performed by a pathology laboratory. U-DPS initiates sending the messages. In order to do so, a script will be started regularly to determine if any authorized reports are available to be provided Specification of message composition (segments) The Unsolicited Laboratory Observation Message ORU^R01 uses the following HL7 v2.4 segments: Segment Description MSH Message header PID Patient identification [ PV1 ] Patient visit (optional) [ ORC ] Order communication (optional) OBR Observation Report ID { [ OBX ] } Observation Results The original requestor, in this case the receiving system (order placer), receives the Unsolicited Laboratory Observation Message ORU^R01, and replies with an acknowledgment message containing the following segments: Segment MSH MSA Description Message header Message acknowledgment 5.2. MSH segment Table 17: HL7 Attribute Table - MSH - Message Header SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 1 ST R Field Separator 2 4 ST R Encoding Characters ^~& HD O Sending Application Contents agreed on by all parties concerned HD O Sending Facility Contents agreed on by August 22, 2013 Order and result messages for pathology information systems 32

33 all parties concerned HD O Receiving Application Contents agreed on by all parties concerned HD O Receiving Facility Contents agreed on by all parties concerned 7 26 TS R Date/Time Of Message Format: YYYYMMDDhhmmss 8 40 ST O Security 9 13 CM R 0076/ Message Type ORU^R ST R Message Control ID DPS ID 11 3 PT R Processing ID P VID R Version ID NM O Sequence Number ST O Continuation Pointer 15 2 ID O Accept Acknowledgment Type 16 2 ID O Application Acknowledgment Type 17 3 ID O Country Code ID O Y Character Set CE O Principal Language Of Message ID O Alternate Character Set Handling Scheme ID O Y Conformance Statement ID 5.3. PID segment Tabel 18: HL7 Attribute Table PID Patient identification SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 4 SI O Set ID - PID 2 20 CX B Patient ID CX R Y Patient Identifier List Patiëntnummer (Patient number) note PID CX B Y Alternate Patient ID - PID XPN R Y Patient Name Naam patiënt note PIDP XPN O Y Mother s Maiden Name 7 26 TS O Date/Time of Birth Geboortedatum note PIDP 8 1 IS O Administrative Sex Geslacht note PIDP XPN B Y Patient Alias CE O Y Race XAD O Y Patient Address August 22, 2013 Order and result messages for pathology information systems 33

34 12 4 IS B County Code XTN O Y Phone Number - Home XTN O Y Phone Number - Business CE O Primary Language CE O Marital Status CE O Religion CX O Patient Account Number ST B SSN Number - Patient DLN O Driver's License Number - Patient CX O Y Mother's Identifier CE O Y Ethnic Group ST O Birth Place 24 1 ID O Multiple Birth Indicator 25 2 NM O Birth Order CE O Y Citizenship CE O Veterans Military Status CE B Nationality TS O Patient Death Date and Time 30 1 ID O Patient Death Indicator 31 1 ID O Identity Unknown Indicator IS O Y Identity Reliability Code TS O Last Update Date/Time HD O Last Update Facility CE C Species Code CE C Breed Code ST O Strain CE O Production Class Code Note PID3: The element Patient Identifier List will be used for providing the local patient number, but also for patient numbers of other hospitals or institutions. This element is also used for the BSN, in case this is available in the U-DPS report. Note PIDP: Although patient identification can be completely performed on the HIS side based on the local patient number, some of the HIS representatives prefer to be provided with patient data such as the name and/or date of birth and/or gender. In agreement with each software vendor separately it has to be decided on which of these elements will be delivered by the U-DPS. August 22, 2013 Order and result messages for pathology information systems 34

35 5.4. PV1 segment In the optional PV1 segment the only important element is PV1-19 Visit number for some Hospital Information Systems. In most cases this concerns the information that has to be provided concerning a specific health problem number, the so-called ziektegevalnummer ORC segment This is an optional segment and only of importance when order communication is also used OBR segment Table 19: HL7 Attribute Table OBR Observation Request SEQ LEN DT OPT RP/# TBL# ITEM # ELEMENT NAME U-DPS 1 4 SI O Set ID - OBR Volgnummer (Sequence number) 2 22 EI C Placer Order Number note OBR EI C Filler Order Number + note OBR CE R Universal Service ID note OBR4 5 2 ID B Priority - OBR 6 26 TS B Requested Date/Time 7 26 TS C Observation Date/Time # Datum van ontvangst (reception date) 8 26 TS O Observation End Date/Time # Datum van verzending (bij definitief verslag) (Date when sent in case of final report) 9 20 CQ O Collection Volume * XCN O Y Collector Identifier * 11 1 ID O Specimen Action Code * CE O Danger Code ST O Relevant Clinical Info TS C Specimen Received Date/Time * CM O Specimen Source * Aard materiaal (kind of material) XCN O Y Ordering Provider Aanvrager onderzoek (gecodeerd) note OBR16 (Order filler code) XTN O Y/ Order Callback Phone Number ST O Placer Field ST O Placer Field ST O Filler Field ST O Filler Field TS C Results Rpt/Status Chng - Date/Time + August 22, 2013 Order and result messages for pathology information systems 35

36 23 40 CM O Charge to Practice ID O Diagnostic Serv Sect ID Hoofdafdeling note OBR24 (Main department) 25 1 ID C Result Status + note OBR CM O Parent Result TQ O Y Quantity/Timing XCN O Y/ Result Copies To ontvangers van kopieën van het verslag van de resultaten CM O Parent ID O Transportation Mode CE O Y Reason for Study note OBR28 (Recepients of copies of the results report) CM O Principal Result Interpreter CM O Y Assistant Result Interpreter + note OBRI note OBRI CM O Y Technician + note OBRI CM O Y Transcriptionist TS O Scheduled Date/Time NM O Number of Sample Containers * CE O Y Transport Logistics of Collected Sample * CE O Y Collector s Comment * CE O Transport Arrangement Responsibility ID O Transport Arranged 42 1 ID O Escort Required CE O Y Planned Patient Transport Comment CE O Procedure Code CE O Y Procedure Code Modifier CE O Y Placer Supplemental Service Information CE O Y Filler Supplemental Service Information Note OBR2: This is the request identification (order number), issued by the application placing the order. In the component namespace the code of this application is added. This field corresponds to the field with the same name in the ORC-segment. In U-DPS the contents of the field ordernummer (order number) are mentioned, should they be available. August 22, 2013 Order and result messages for pathology information systems 36

37 Note OBR3: This is the report number from the pathology department (unique reference to the report containing the study results). Furthermore see note ORC3, par Note OBR4: this element contains the type of study. For pathology these are: Histologie (Histology) Cytologie (Cytology) Obductie (Autopsy) Cervixcytologie (Cervixcytology) Note OBR16 The notation to use is ordering provider number or researcher, optionally completed with the name: <code>^<naam> The ordering provider number corresponds with the number the HIS uses as a unique identification of the healthcare professional in the hospital. This can also be a number for a healthcare professional working in the primary care sector. U-DPS has a field codeaanvrager ( requestor code ). The value of this field almost never corresponds to the number the hospital uses. For this reason, the contents of the field codeaanvrager from the order filler file of U-DPS is used to derive the ZIS code. Note OBR24 At HIS vendor CSC the TH5-code is expected from the order filler (department). Note OBR25 In almost all situations code F meaning final results is used. When sending reports that are still under consideration (status: in behandeling ), the code I (large i) is used. Note OBR28 OBR-28 is optional. It is used to add information about recipients of a copy of the report. These recipients are registered in U-DPS using a code in the tab Copie (Copy). Note: The U-DPS contains a field code(copie), but the value of this field nearly never corresponds to the number the hospital uses. For this reason, the contents of the field codeaanvrager from the order filler file of U-DPS is used to derive the ZIS code. In most cases only the first two components are used (number and name). Note OBRI In most cases, when effectuating the results of the study, at least a pathologist is concerned. Note: In a U-DPS report the pathologist is registered using a code. This is a local code, in most August 22, 2013 Order and result messages for pathology information systems 37

38 cases not corresponding to the code that the pathologist is known in the hospital by. This code will therefore be diverted using the local pathologist code in the report. For both the pathologist resident and the analyst the same method applies OBX segment Table 20: HL7 Attribute Table OBX Observation SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME U-DPS 1 4 SI O Set ID - OBX Serial number of the OBX segment 2 2 ID C Value Type FT CE R Observation Identifier note OBX ST C Observation Sub-ID * C Y Observation Value Result study text CE O Units 7 60 ST O References Range 8 5 IS O Y/ Abnormal Flags 9 5 NM O Probability 10 2 ID O Y Nature of Abnormal Test 11 1 ID R Observation Result Status note OBR TS O Date Last Observation Normal Value ST O User Defined Access Checks TS O Date/Time of the Observation CE O Producer's ID XCN O Y Responsible Observer CE O Y Observation Method EI O Y Equipment Instance Identifier TS O Date/Time of the Analysis Note OBX3: This code contains a description of the performed study. Components: <identifier>^<text>^<name of coding system>^ <alternate identifier>^<alternate text>^<name of alternatecoding system> Together with <name of coding system>, as a rule, L (for local ) will be used. An alternative code can be added as well. Other possible components are not used. In Table 21 the values for identifier are specified. August 22, 2013 Order and result messages for pathology information systems 38

39 Table 21: possible values for the identifier component for OBX-3 Pathology item Code LOINC description Namespace Klinische gegevens (= tekst aanvraag onderzoek) (Clinical information text study request) Macroscopie (Macroscopy) Path Report.Relevant HX LN Path. Report.gross observation LN Microscopie (Microscopy) Path. Report microscopic observation LN Epicrise (discharge summary) Pathologic findings LN Protocol Pathology procedure note LN Conclusie (vh totale onderzoek) Diagnosen (Diagnoses) Aanvullend onderzoek (lokaal1) (additional study, local1) Signalering (melding van externe complicaties) (Signal indication of external complications) Pathology report.total LN Pathology report. Final diagnosis LN AANVUL (not LOINC, but own code) L SIGNALERING (not LOINC, but own code) L Titel in overleg (Title to be decided on in cooperation) lokaal1, lokaal2, lokaal3 (not LOINC, but own code) L Examples: OBX 1 FT ^^LN Text belonging to macroscopy F OBX 2 FT ^^LN Text belonging to macroscopy F... OBX 5 FT AANVUL^^L Text additional study F Essentially, the message receiver has to convert the identifier into a human readable title. This should be agreed upon. Most of the studies are performed based on a set of guidelines and protocols. Also, registration of the study and reporting the study itself can be predefined and registered separately and made available for information exchange: protocol name, protocol data and reporting according to protocol. The protocols are added in the OBX segment, using LOINC code The generic format is as follows: \.in+4\\.ti-4\protocoltag1: text1\.sp\\.ti-4\protocoltag2: text2\.sp\\.ti-4\... August 22, 2013 Order and result messages for pathology information systems 39

40 At the beginning of the text concerning the report according to protocol, the element \.in+4\ is added. After that, for each line, the item \.ti-4\ follows, together with the protocol tag (protocoltag, e.g. Protocolversie meaning protocol version, or Aantal poliepen meaning number of polyps), followed by a : (colon) and the corresponding report text (text). The line is closed using an \.sp\. This way a report text can always contain a syntax to indicate the tags and values, since the tag is always enclosed by a \.ti-4\ and a : (colon). Example: OBX 7 FT ^^LN \.in+4\\.ti-4\protocolnaam: Colon rectum carcinoom\.sp\\.ti-4\protocolversie: 7\.sp\\.ti-4\Protocollaire beschrijving: tekst\.sp\\.ti- 4\Aantal poliepen: 0... F August 22, 2013 Order and result messages for pathology information systems 40

41 H-6 Confirmation of receiving result message After receiving the result message from the pathology laboratory, the order placer confirms receiving the results by sending an ACK^R01 message. This message contains the following HL7 v2.4 segments: Segment MSH MSA Description Message header Message acknowledgement This message corresponds to a Lab Order Message OML^O21 with an MSH and an MSA segment. The MSH-9 element for an ACK^R01 message contains the value ACK^R01. August 22, 2013 Order and result messages for pathology information systems 41

42 H-7 Appendix I 7.1. Communication TCP/IP based on a socket connection is used for communication to and from an external information system. The IP-address/server name and socket can be adjusted MLLP In case of socket communication, using the so-called Minimum Lower Layer Protocol MLLP is preferred U-DPS attributes concerning the HL7 connection The U-DPS has the following functionalities for receiving and processing the digital orders that are delivered to U-DPS: At port 9700 a server is listening continuously. Also, this server receives the messages that are delivered. Port 9700 is the port that is configured as the standard port in U-DPS. If needed, the value of this port can be changed if agreed upon by the concerned parties. Immediately after receiving an order, a message is sent to the order filler system, confirming the reception. The order is saved in U-DPS in a certain manner until it is incorporated into a study report. When providing the study results, the order number is delivered as well. August 22, 2013 Order and result messages for pathology information systems 42

43 H-8 Appendix II 8.1. Concepts Concept PALGA Foundation (Stichting PALGA) U-DPS Description National Pathologic Anatomic Automated Archive, see Uniform Decentralized PALGA System. A system that is facilitated by PALGA for reporting in pathology laboratories. August 22, 2013 Order and result messages for pathology information systems 43