Minutes of September 2000
Orders/Observations Worksession
Attendee / Company/E-Mail / Mon AM / Mon PM / Tue AM / Tue PM / Wed AM / Wed PM / Thu AM / Thu PM / Fri /Liora Alschuler / / Ö /
Kay Avant / / Ö / Ö
Calvin Beebe / / Ö
Fred Behlen / / Ö
Paul V. Biron / / Ö
Sandy Boyer / / Ö / Ö / Ö
Tina Buckeye / / Ö / Ö / Ö / Ö / Ö / Ö
Hans Buitendijk / / Ö / Ö / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Jim Case / / Ö / Ö / Ö / Ö
Carmella Couderc / / Ö
Curt Coulter / / Ö / Ö / Ö
Amy Danko / / Ö
Bob Dolin / / Ö / Ö
Joachim Dudeck / / Ö
Lou Dunka / / Ö
Shari Dworkin / / Ö
Al Figler / / Ö
Jay Gaeta / / Ö
Barry Gordon / / Ö / Ö / Ö
Louis R. Gordon / / Ö
Kenzo Gushiken / / Ö
Dick Harding / / Ö
Charles Hawker / / Ö
Masaaki Hirai / / Ö
Frank Howard / / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Stan Huff / / Ö / Ö
Peter Johnson / / Ö / Ö / Ö
Joan Kapusnik-Uner / / Ö / Ö
Martin Kernberg / / Ö
Jerry Kirchner / / Ö / Ö
Andrzej J. Knafel / / Ö / Ö / Ö
Helmut König / / Ö
Diane Kravec / / Ö / Ö
Austin Kreisler / / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Ed Larson / / Ö
Joann Larson / / Ö / Ö / Ö
Bill LeClair / / Ö
Andrei Leontiev / / Ö
Michael Macaluso / / Ö
David Markwell / / Ö
Tom Marley / / Ö / Ö / Ö
Ken McCaslin / / Ö / Ö / Ö / Ö / Ö / Ö
Charles McCay / / Ö
Clem McDonald / / Ö / Ö
Gary Meyer / / Ö
Galen Mulrooney / / Ö
Manish Narang / / Ö / Ö
Thanh-Le Nguyen / / Ö
Karen Nocera / / Ö / Ö
Herman Oosterwijk / / Ö
Daniel Pollock / / Ö
Alan Rector / / Ö
Harry Rhodes / / Ö
Scott Robertson / / Ö / Ö / Ö / Ö / Ö / Ö
David Robinson / / Ö
Angelo Rossi Mori / / Ö
Alan Rowberg / / Ö
Dan Russler / / Ö / Ö
Jerry Sable / / Ö
Gunther Schadow / / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Karen Sieber / / Ö / Ö
Alan Sim / / Ö
Doug Sluis / / Ö
David Snavely / / Ö
Kent Spackman / / Ö
Michael Stearns / / Ö
Helen Stevens / / Ö / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Sean Sudduth / / Ö
Sadamu Takasaka / / Ö
Timo Tarhonen / / Ö / Ö
Alfredo Tirado-Ramos / / Ö
Robin Todino / / Ö
Wayne Tracy / / Ö / Ö / Ö / Ö / Ö / Ö
Cheryl Tyus / / Ö
Serafina Versaggi / / Ö
Heather von Allmen / / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Gina Wade /
Steve Wagner / / Ö
Judy Warren / / Ö
Mead Walker / / Ö
Andrew Woyak / / Ö
Daphne Young / / Ö / Ö / Ö / Ö / Ö / Ö / Ö
Communication with declared O&O participants can be done through . You can sign up on this list through HL7’s home page www.hl7.org.
Monday, September 12, 2000
Need to synchronize the Specimen Source discussion with Laboratory, Point of Care, and Automated Testing SIG
V2.x Proposals
Add NK1 Segment to ORM message
Proposal
Add NK1 Segment to ORM message
Summary
This is a request to add the NK1 segment to the ORM message in the next 2.x release of HL7. The NK1 segment was added to the ORU message for unsolicited observation message in HL7 Version 2.3.1, however, it was not included in the ORM. This information is typically gather by the placer and will need to be included in the ORM message particularly when the information is mandated to be reported to state agencies based on specific test requests (example: heavy metals and sexually transmitted diseases.
ORM general order message (O01)
The function of this message is to initiate the transmission of information about an order. This includes placing new orders, cancellation of existing orders, discontinuation, holding, etc. ORM messages can originate also with a placer, filler, or an interested third party.
The trigger event for this message is any change to an order. Such changes include submission of new orders, cancellations, updates, patient and nonpatient-specific orders, etc.
ORM^O01^ORM_O01 / General Order Message / ChapterMSH / Message Header / 2
[{NTE}] / Notes and Comments (for Header) / 2
[
PID / Patient Identification / 3
[PD1] / Additional Demographics / 3
[{NK1}] / Next of Kin/Associated Parties / 3
[{NTE}] / Notes and Comments (for Patient ID) / 2
[PV1 / Patient Visit / 3
[PV2]] / Patient Visit- Additional Info / 3
[{IN1 / Insurance / 6
[IN2] / Insurance Additional Info / 6
[IN3] / Insurance Add’l Info - Cert. / 6
}]
[GT1] / Guarantor / 6
[{AL1}] / Allergy Information / 3
]
{
ORC / Common Order / 4
[
Order Detail Segment OBR, etc. / 4
[{NTE}] / Notes and Comments (for Detail) / 2
[{DG1}] / Diagnosis / 6
[
{
OBX / Observation/Result / 7
[{NTE}] / Notes and Comments (for Results) / 2
}
]
]
{[CTI]} / Clinical Trial Identification / 7
[BLG] / Billing Segment / 4
}
Discussion
Proposal to add to ORM is not valid as the ORM is for ‘backward compatibility only’ as of HL7 2.4.
Wayne: National Cancer Registry also has use case to support implementation of NK1 in ORU messages (ORU already includes NK1). For consistency NK1 should be included in the ‘family’ of order/observation messages.
There are no use cases presented to add NK1 to pharmacy, dietary and supply messages at this time.
Austin Motion: Modify proposal to add NK1 to OML (Laboratory order) and OMG (General order) immediately following the PID/PD1/NTE segments.
Vote: for 14, 0 against
Helen motion: Move the NK1 in the ORU message to follow immediately after the PID/PD1/NTE segments as the NTE applies to the PID/PD1 not the NK1 segment. This is to correct an error in the original placement of the NK1.
Vote: for 14, 0 against
Joann volunteers to raise the issue with CQ of placement of the NTE or the documentation of what segment the NTE applies to.
OBR – Special Instructions Proposal
Problem:
It is unclear where “special instructions” information for a test/service (e.g., draw specimen from left arm) should be transmitted.
At the working group meeting in San Diego we proposed that the Note segment (NTE) be used. This recommendation was not endorsed.
Another solution put forth was to transmit “special instructions in either the ORC-7 or OBR-27 in component-8 “text” of the TQ data type. However, the Orders TC agreed in January 2000 that only quantity or timing information such as “collection time” should be sent in this component. Designation of a proper field for “special instructions” that are neither timing nor quantity issues was tabled until such time as a new proposal could be submitted.
Proposed Solution:
Add a new field “Special Instructions” to the OBR as follows:
OBR observation request segment
HL7 Attribute Table - OBR
SEQ / LEN / DT / OPT / RP/# / TBL# / ITEM# / ELEMENT NAME /48 / 250 / ST / O / Special instructions
Special instructions (ST)
Definition: This field contains any “special instructions” information from the ordering provider to the filler that may be necessary and not elsewhere transmitted for a test/service.
Examples: Draw specimen from left arm; isolation precautions.
NOTE: “Isolation precautions” example needs further evaluation—may overlap with the unfortunately labeled OBR-12 Danger code.
Decision: Use OBR:15 and OBR:12 for specific use cases given. Kaiser to investigate if there are other use cases and re-present.
MDM vs ORU Proposal – Kaiser Permanente
* This proposal was accepted by the Medical Record TC contingent upon approval by Orders and Observation TC
We have been implementing transcription messages at Kaiser Permanente and have found considerable difficulty in interpreting the HL7 Standard. For example, if the reader is looking for direction on what message to use for a transcribed lab pathology report the standard is ambiguous. After reading the Document Management (MDM) messages as described in section 9.4 of chapter 9, it would appear that the MDM message is appropriate, although lab pathology is not a suggested value in user-defined table 0270 Document Type as used in TXA-2 Document Type. Section 7.1 of chapter 7 speaks broadly and vaguely about structured reports. The reader is not referred elsewhere, such as chapter 9, for transcribed reports. Indeed, the presence of a Transcriptionist field in the OBR segment, specifically OBR-35 suggests that the ORU is a valid mechanism for transmitting transcription reports.
We believe that HL7 should clearly and unambiguously designate which message is to be used for transcription; there should not be 2 applicable to the same function.
Problem statement:
The following problems have arisen:
1. We attempted to set the MDM message as our standard for all transcription. We found that we needed to have the ORC/OBR for those transcription results tied to an explicit order, specifically because the MDM message does not contain fields for Ordering Provider and the Ordered Procedure. Consequently, we reverted back to the ORU message for transcription associated with an explicit order. This made our Lab, Radiology, and Electrodiagnostic systems happy because they are familiar with the ORU message. [In the meantime Medical Records TC has approved the inclusion of the ORC/OBR for the next balloting cycle.]
2. We attempted to reserve the MDM for transcription not having an explicit order. Our users have informed us that the distinction is arbitrary. Furthermore, transcription systems may have difficulty sending 2 different messages (MDM and ORU depending on the type of report coming through) when it appears to them that the ORU serves both purposes.
3. We explored abandoning the MDM message in favor of using the ORU for all transcription reports. We discovered that this made sending documents such as Progress Notes and Discharge Summary, unnecessarily cumbersome. We would have difficulty, for example, populating the required OBR segment, especially OBR-4.
4. We explored using both messages but found it was difficult to define when one should be used over the other. There is considerable overlap between the MDM and the ORU without clear language guiding the user. It might be hard to get agreement, for example, as to whether a transcribed Consultation report would require the ORU or the MDM.
Pros of the MDM: It’s concise without unnecessary segments (except the EVN). The segment format and data elements are ideal for documents that are not associated with explicit orders. We are not forced to populate non-relevant segments or fields. The trigger events (T01, T02, ect.) are nice for those who need to use them.
Cons of the MDM: The EVN segment is not necessary. An optional NOTE for OBX segment is missing. Many fields within the ORC or the OBR segments cover much of the information in the TXA segment. Examples:
TXA-7 and TXA-11 can be found in OBR-35;
TXA-9 = OBR-32;
TXA-23 = OBR-28;
TXA-14 = ORC-2 and OBR-2;
TXA-15 = ORC-3 and OBR-3;
Pros of the ORU: For functions of ordered results (as in Lab, EKG, and Radiology), the ORU message is familiar and fits the need exactly. Users are happy to stay with ORU.
Cons of the ORU: If we are dealing with non-ordered results (e.g., medical progress notes, etc.) there are issues with valuing some required fields to contend with. For example: ORC-2 and ORC-3 (or OBR-2 and OBR-3), as well as the OBR-4 fields.
The purpose of the required EVN segment in the MDM is not clear. Our users balk at populating it. There is only one required field (EVN-2), the Recorded Date/Time, which is the same as TXA-7 for a transcribed report. The remaining 5 fields are optional or retained for backward compatibility.
Proposed solution:
1. Add explanatory language to the ORU explaining if and when it should be used as opposed to the MDM. Conversely, add explanatory language to the MDM explaining when it should be used as opposed to the ORU.
2. In the next balloting cycle, the Medical Records TC will propose the inclusion of the ORC/OBR along with new trigger events to accommodate sending Results associated with explicit orders using MDM message. We suggest the removal of the EVN segment from the MDM message requirements.
3. If the ORU is retained as a legitimate transcription message, assign a unique trigger event so that appropriate segment optionality can be defined.
4. If the ORU is retained as a legitimate transcription message, modify the grammar to include the TXA and deprecate the OBR-35.
Chapter 7 - Purpose
This chapter describes the transaction set required for sending structured patient-oriented clinical data from one computer system to another. A common use of these transaction sets will be to transmit observations and results of diagnostic studies from the producing system (e.g., clinical laboratory system, EKG system) (the filler), to the ordering system (e.g., HIS order entry, physician’s office system) (the placer). However, the transaction set is not limited to such transactions. Observations can be sent from producing systems to archival medical record clinical information systems (not necessarily the order placer) and from such medical record systems to other systems that were not part of the ordering loop, e.g., an office practice system of the referring physician for inpatient test results ordered by an inpatient surgeon. This chapter also provides mechanisms for registering clinical trials and methods for linking orders and results to clinical trials and for reporting experiences with drugs and devices.
These transaction sets permit the transmission of any kind of clinical observations including (but not limited to) clinical laboratory results, the results of imaging studies (excluding the image), EKG pulmonary function studies, measures of patient status and condition, vital signs, intake and output, severity and/or frequency of symptoms, drug allergies, problem lists, diagnostic lists, physician and nursing history, physicals, progress notes, operative notes and so on.