Results Reporting Interface Specifications For Results Sent from IntelliPath

Transcription

1 The standard format for sending patient related information from one system to another is the HL7 (Health Level Seven) protocol. The HL7 protocol defines various types of messages that are composed of a set of segments, which contain the patient s data in delimited fields. The results sent to the hospital information system are usually of the message type ORU (Observation Results, Unsolicited). The messages and segments are defined below. MESSAGES An HL7 message contains a single patient record. It is composed of a set of segments sent in a pre-defined sequence and hierarchy. Each segment type is identified by a unique 3-character code called the Segment ID, and the Segment ID is the first field of each segment. Each segment is composed of a group of data fields separated by a field separator character. The field separator and other encoding characters are defined in the BHS and MSH segments. Each segment must be followed by an ascii 13 (carriage return) character. For results reporting, the IntelliPath interface uses the following segments in the following order. Some segments may be optional and some may be repeated. Message Structure BHS Batch Header Segment [required] MSH Message Header Segment [required] PID Patient Identification Segment [required] PV1 Patient Visit Segment [required] OBR Observation Request [required][may be repeated] OBX Result [required] [may be repeated] BTS Batch Trailer segment [required] SEGMENT DEFINITIONS Fields not currently used by IntelliPath system are not listed. Any field that is not used should be nil, and trailing empty fields should be omitted. BHS BATCH HEADER SEGMENT 1 BHS 2 Field separator and encoding characters: field separator ^ component separator ~ repetition separator \ escape character & sub-component separator 3 Sending application IntelliPath 4 Sending facility??? 5 Batch Receiving application??? 6 Batch Receiving facility??? 7 Batch Creation Date/time of message, format YYYYMMDDHHMMSS Date BTS BATCH TRAILER SEGMENT BTS 1 Batch message count, count of messages in batch 05/03/10, 1:23 PM, page 1

2 MSH MESSAGE HEADER SEGMENT 1 MSH 2 Field separator and encoding characters: field separator ^ component separator ~ repetition separator \ escape character & sub-component separator 3 Sending application IntelliPath 4 Sending facility??? 5 Receiving application??? 6 Receiving facility??? 7 Date/time of message, format YYYYMMDDHHMMSS 8 <not used> No 9 Message type, ORU^R01 for results reporting ORU^R01 10 Message control ID, a unique identifier for this message on the sending system No 11 Processing ID, P for production, T for test, and D for development P 12 HL7 Version number. 2.3 PID PATIENT IDENTIFICATION SEGMENT PID 1 Set ID, value of 1, since we will have only 1 patient per message 2 <not used> No 3 Patient ID, Medical Record Number or History Number if entered IntelliPath internal unique ID for patient 4 <not used> 5 Patient name, in format LAST^FIRST^MIDDLE Last^First^Mi ddle 6 <not used> No 7 Date of birth, in format YYYYMMDD 8 Patient sex 9 Patient Alias No 10 Race 11 Patient Address 12 County Code No 13 Phone Number Home 14 Phone Number Business 15 Language No 16 Marital Status No 17 Religion No 18 Visit number Lab Account Number if entered 19 SSN ###-##-#### PV1 PATIENT VISIT SEGMENT PV1 7 Attending MD, in format MDCODE^LASTNAME^FIRSTNAME No 8 Referring MD, in format MDCODE^LASTNAME^FIRSTNAME 9 Consulting MD, in format MDCODE^LASTNAME^FIRSTNAME 05/03/10, 1:23 PM, page 2

3 19 Visit Number No 39 Hospital site (Primary Doctors Location) No OBR OBSERVATION REQUEST SEGMENT OBR OBR 1 Set ID, number of this OBR segment in this message 2 <not used> No 3 Accession Number. IntelliPath internal unique ID for patient and visit 4 <not used> No 6 <not used> No 7 Observation Date/time of service in format YYYYMMDD 8 (Observation End Date/Time) Collector Identifier No 14 Specimen Received Date/Time in format YYYYMMDDHHMM 15 Specimen Source Not Available for Cytology Cases Source code^ source text 16 (Ordering Provider) Ordering MD, in format CODE^LASTNAME^FIRSTNAME 18 Placers field #1, for special use field not defined elsewhere No 19 Specimen Identifier Not Available for Cytology Cases 20 Fillers field #1, for special use field not defined elsewhere No 21 Fillers field #2, for special use field not defined elsewhere No 22 Results Report/Status Change No 24 Diagnostic Service Section ID SP (dx service) 25 Status: F for final, D for delete, C for correction, X for order cancelled, P for F or C preliminary, I for specimen in lab results pending. 32 Principal result interpreter, in format CODE^LASTNAME^FIRSTNAME 33 Assistant result interpreter, in format CODE^LASTNAME^FIRSTNAME No OBX OBSERVATION RESULT SEGMENT OBX OBX 1 Set ID, number of this OBX segment in this message 2 Value Type CE,TX 3 Observation ID, unique ID for observation. This field has two components CODE^TEXT. This can be used to define a specific test or the section of a report ICD9^ICD9 Code CLT^Clinical GDT^Gross The following will be used for Surgical Cases Only: FD^Final Diagnosis DXC^Diagno 05/03/10, 1:23 PM, page 3

4 sis Comment FT^Frozen Diagnosis GDT^Gross MDT^Micros copic Description CC^Case Comment The following will be used for Cytology Cases Only: ADQ^Adequa cy ADQM^Adeq uacy Modifier ADQT^Adeq uacy Free DIA^Diagnos is DIAM^Diagn osis Modifier DIAT^Diagn osis Free REC^Recom mendation RECT^Reco mmendation Free HOR^Hormo nal HORT^Horm onal Free COM^Comm ents COMT^Com ment Free 4 Observation sub-id. Number of the OBX segment for the current Observation ID. For labs this is the result test. 5 Observation results. We will send a single paragraph at a time. 6 Units, for numeric results No 7 Reference Range No 8 Abnormal flag. No 11 Status: F for final, D for delete, C for correction, X for order cancelled, P for F or C 05/03/10, 1:23 PM, page 4

5 preliminary, I for specimen in lab results pending. 14 (Date/Time of Observation) Date/time result was finalized, in format YYYYMMDDHHMMSS No FILE STRUCTURE BHS - BHS Segment MSH - MSH Segment PID - PID Segment PV1 - Patient Visit Segment OBR - Observation Segment OBX segments Result Segments separated by \r OBR - next Observation segment for same case OBX segments - Result Segments for this Observation segment - separated by \r MSH (Next case) PID - PID Segment PV1 - Patient Visit Segment OBR - Observation Request Segment OBX segments - Observation Result segments separated by \r OBR - Next Observation Request segment for same case OBX segments - Observation Result Segments for this Observation segment - separated by \r BTS - Batch Trailer Segment 05/03/10, 1:23 PM, page 5