2020-12-15 Meeting Notes

15 Dec 2020 10:00 AEDT

Attendees

@Andrew McIntyre (Co-Chair)

@Michael Legg (Co-Chair)

@Dalisay Giffard

@Eric Browne

@Jakub Sielewicz

@Jared Davison 

@Kyle Macdonald

@Philip Wilford

@Scott Ferris

@Tarun Narayan

@Tony Cruice

@Vincent McCauley

@Vanessa Cameron (Secretariat)

Apologies

@Angus Millar

@Brett Esler

@Christian Holmes

@Danielle Tavares-Rixon

@David McKillop

@Kieron McGuire

@Lars Becker

@Liam Barnes

@Michael Osborne

@Nick Ferris

@Paul Carroll

@Roger Hill

@Robert Flatman

Goals:   1) Address remaining HL7v2-FHIR comments allowing pre-release of draft Standard for public comment

Discussion items (included the following):

 Notes from Meeting 23 on 08 December 2020 were accepted by members in attendance.

 1.     Introduction

Addition of Diagnostic Imaging content by Nick Ferris on behalf of RANZCR:

...

Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4, Release 2 is the Australian localisation of the international HL7 V2 Standard covering the Laboratory/Diagnostics/Clinical result reporting, laboratory/radiology ordering specification and patient referral. The term "Diagnostics" covers non laboratory reporting including reporting of diagnostic imaging and non referral related clinical reporting (for example: echocardiography, respiratory function, endoscopy, stress testing, sleep studies). The term pathology in Australia covers all aspects of laboratory medicine including clinical and anatomical pathology domains. The relationship between Pathology Practices and , while the term “radiology” is understood to include all diagnostic imaging modalities, whether X-ray based or other (eg ultrasound). 

The relationship between pathology and radiology practices and their customers in Australia is considered by Government and others as similar to that between other consultant specialists and their customers. For that reason, what HL7 would call an order is generally called a request here and the response by the pathology provider (a formal term meaning the responsible specialist(s)) is called a report.  For some disciplines such as microbiology, anatomical pathology, genetics and genomics the request is more by way of asking a clinical question expecting the pathology provider to understand the best way of answering it - eg Is this cancer, if so what type, and what is the prognosis? It is expected this form of requesting will become more common as laboratory medicine evolves. In radiology, it is generally necessary for the request to include clinical information relevant to the purpose of the request, to enable the optimal choice, and interpretation, of the examination.  It is also frequently necessary that the request contain information relevant to safety issues that may arise from performance of the test, such as contrast allergies, renal disease, etc.

The use case here focuses on widely-available, well-standardized methods that will support the secure access to electronic laboratory orders and radiological requests and results and interpretations for clinical care by authorized parties and is driven by the need for timely electronic access to requested, referred and historical lab results. Requesting clinicians (the Placer) receive test results in the form of a HL7 V2 message, as a response to a request (electronic or paper) or as an unsolicited message by having the report directly sent by the pathology practice (the Filler) to the clinician for importation into their local systems. Images generated in the course of a radiological procedure are not sent in an HL7 message. Depending on the referrer’s requirements, and local technical capabilities, images may be made available on traditional analogue film (rapidly becoming obsolete), portable digital media, or, increasingly, in digital form via an online electronic portal.

Referral messaging covers clinical referral between clinicians and hospitals, as well as hospital discharge and includes a patient history summary suitable for constructing a Virtual Medical Record for use in decision support and can include any pathology/radiology/diagnostics reports relevant to the referral. It also includes a Medication summary. 

This document tries to provide coverage for all laboratory messaging laboratory and radiological messaging scenarios in the Australian context including public and private entities, hospital and community and public health entities. The referral messaging covers referral between medical practitioners, allied health and hospitals. It covers referral between practitioners, referral to hospitals and hospital discharge.

The Royal College of Pathologists of Australasia (RCPA) has developed a number of policies around safety in requesting and reporting of pathology including the use of terminology and the transmission of data.  These policies have been incorporated into this document. Similarly, the Royal Australian and New Zealand College of Radiologists has defined minimum requirements for the content of referrals and reports.  Standardised terminology for radiological procedures is being developed, and will be progressively implemented throughout the sector.

This document and the specifications in it supersede those in AS 4700.2-2012 - Implementation of Health Level Seven (HL7) Version 2.4 - Pathology and diagnostic imaging (diagnostics) and HB 262 (Rev)-2012 - Guidelines for messaging between diagnostic providers and health service providers, and AS 4700.6-2006 Implementation of Health Level Seven (HL7) Version 2.4 Part 6: Referral, discharge and health record messaging.

...

This guide contains the necessary specifications for pathology and radiology requests and reports in Australian healthcare using the HL7 V2.4 protocol. Where appropriate aspects of later versions of HL7 V2  have have been incorporated into this localization. Where this is done it is flagged as a variation from v2.4.

...

2.     Patient Administration for Pathology

2.1.9.12  MSH-12 Version ID (VID) 00012

HL7 Table 0104 – Version ID

Internal version ID value: HL7AU-OO-REF-SIMPLIFIED-201706

this contradicts the value referenced here - Appendix 8 Simplified REF profile (Normative)#A8.4.1ReferralLevel1

assuming this needs to be HL7AU-OO-REF-SIMPLIFIED-201706/RRI as the internal version id

or the first occurrence of the segment, the sequence number shall be one, for the second occurrence, the sequence number shall be two, etc.  All agreed to retain current ID values as per 2.1.9.12.  Unique internal version ID values allow SMD agents to easily map to URIs for directory lookup.

2.2.1.1 PID-1 Set ID PID (SI) 00104 – PID-1 is mandatory in AU context.

2.2.1.5 PID-5 Patient name (XPN) 00108 – What is the minimum requirement for name? I am aware that Genie requires at least the first and last names to import a message. Should legal name be the minimum requirement?  There are a range of clinical practice scenarios e.g. Unconscious and unidentified patients in Emergency; Sexual Health Clinic coded patients; VIP patients; Newborns identified as Baby of (mother), etc where non-legal names are used to identify patients and this needs to be supported. 

2.2.2.9 PC1-9 Consulting doctor (XCN) 00139 – Add a new subsection about mapping FHIR provider directory entries. Similar to A8.12.2 Intended Provider/Individual recipient level addressing.  Issue 1: resolved by Appendix 10 e.g. Optional for ORM.  Issue 2: We don’t see a valid use case for mandatory intended recipient for ORM.

2.2.4 AL1 – Patient allergy information segment Item 00207Allergy Reaction Code – This appears very small for a repeating element. Field length increased from 15 to 250.

3.     Datatypes

3.3.3 Name of coding system (IS) –

Decision to review when Kieran is present in future meeting.

 4.     Observation Reporting

4.4.1.13 OBR-13 Relevant clinical information (ST) 00247  – Could we either consider changing this field to FT or making \.br\ valid for the ST datatype. If there are multiple separate additional clinical information points in this field it will make it easier to read if they are on separate lines.  Possible OBX LOINC codes: https://loinc.org/90371-6/ or https://loinc.org/81192-7/ .  Seek guidance from Peter Scott as to which LOINC code should be used for this purpose.  Post meeting, Peter Scott provided the following advice:  see 4.4.1.13 OBR-13 Relevant clinical information (ST) 00247 above. 

LOINC has the following choices I can see for clinical notes to go with an order. (I have excluded  90371-6 Clinical pathology note and 90011-8 Clinical pathology Progress note, as these seem to be for pathologists who are also clinicians entering patient progress notes, eg haematologists)

I suggest:

 64436-9 Clinical or research indication for test (NB this is a PhenX code)
 55752-0 Clinical information 
 75321-0 Clinical finding 
 82610-7 Note  

82610-7 is a bit of an allrounder that can get contextualised for semantic searches from the structure of the data in the EHR/LIS.  55752-0 is used in a diagnostic imaging panel https://loinc.org/87416-4/ so it could be useful in this context at a general level.

SNOMED however can get closer to the apparent intended semantics, which is for necessary clinical data to allow constraints on the pathology test value and interpretation; rather than a general "clinical notes" IMHO based on the examples above:

23745001:363702006 = 108252007  [Documentation procedure: Has focus = Laboratory procedure]

There is a laboratory request code but it is in the Situation hierarchy and best avoided if possible. Again the convention has been to use a procedure code. As well, postcoordination is problematic for some vendors and jurisdictions. 

Public Comment period ~ 6 weeks, with HL7.au O&O to reconvene Tuesday 02 February 2021 10:00-11:30 AEDT where all feedback received will be reviewed.  GoTo Meeting to be scheduled by Medical Objects.

Thank you to all for your contributions to the HL7.au O&O working group.  Best wishes for the holidays and the New Year.

 Outstanding Meeting actions:

• 17. @Brett Esler  - Update links to all Standards on the HL7 Australia O&O WG page – Australian Diagnostics and Referral Messaging – Localisation of HL7 v2.4 Standard is still referenced as ‘Current Draft Standard’ as per  https://confluence.hl7australia.com/display/OO/Current+Draft+Standards
• 32. @Kieron McGuire - Contact @Brett Esler to have pages for Profile URIs (FHIR Provider Directory) & update link for FHIR R4 Value sets to return user to correct version of HL7 Standard
• 33. @Jared Davison – create a checklist prior to final draft Standard being published
• 41. @David McKillop to provide presentation on ADHA Diagnostic Report FHIR Implementation Guide (20 – 30 mins) after 06 October meeting
• 43. @Jared Davison to review draft Standard to ensure no other reversions have occurred
• 45. @Jared Davison to prepare PDF of draft Standard
• 64.@Jared Davison tried to move A11.3 The Indication of Consent into draft Standard as an appendix, but has a lot of PCHR-specific content, not generic enough for O&O.  Needs governance to review before next meeting

New Meeting Actions:

• 67. @Vanessa Cameron to identify RCPA Informatics Committee Fellow representative for HL7.au O&O meetings
• 68. @Vanessa Cameron to identify RCPA secretarial support ASAP for ongoing HL7.au O&O meetings
• 69. @Jared Davison to add Diagnostic Imaging content by Nick Ferris on behalf of RANZCR to 1. Introduction
• 70. @Kieran McGuire needs to be in attendance to review proposal for 3.31.6 Degree (IS) – Consider adding AU codesystem for qualifications beginning with 2 codes for V2 compatibility -  Table 0360 Degree compatibility
• 71. @Jared Davison & @Andrew McIntyre - 4.4.1.13 OBR-13 Relevant clinical information (ST) 00247 - add text for instructions for OBX code use. 
• 72. @Jared Davison to make a PDF of ‘Pre-release’ document HL7AUSD-DFC-OO-ADRM-2020.1 Australian Diagnostics and Referral Messaging - Localisation of HL7 Version 2.4.
• 73.  @Jared Davison to provide PDF to @Brett Esler and @Jason Steen asking them to distribute to all HL7.au members on behalf of O&O wg, and other interested parties.  All feedback ‘informal phase’ preferred via Confluence or via email to @Andrew McIntyre or @Michael Legg. 
• 74. @Vanessa Cameron to ask RCPA to distribute ‘Pre-release’ draft to interested parties, especially NPAAC Committee.
• 75.  @Jared Davison to schedule GoTo Meeting for next HL7.au O&O meeting Tuesday 02 February 2021 10:00 AEDT.