GET-IT Specifications v External Documentation v1.01 powered by DXTi

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1 GET-IT Specifications v External Documentation v1.01 powered by DXTi This document contains information relating to the formatting and structure of the base GDML results HL7 specification for external clients. Gamma-Dynacare Medical Laboratories

2 Change History Version Date Author(s) Description Gordon Lo Final Gordon Lo Removed Manitoba specific data from ORC Field 1. Corrected OBR3.1 and OBR 3.2. Corrected OBR4.2 with name rather than description Corrected OBR26 with default result status Updated OBR26 as being populated Corrected OBX3.3 with name rather than description Gordon Lo Updated support for ZDR in Winnipeg LIS Gordon Lo Updated MSH9 updated to GUID for Winnipeg NTE3 and 4 updated for comment code and comment 2 of 57 P a g e

3 Contents Change History... 2 Overview... 4 Structure Governing Rules... 5 Minimal Lower Layer Protocol (MLLP)... 5 HL7 Standard Message... 5 Detailed Descriptions of the Segments... 6 Important Segment Notes... 6 Message Header Segment - MSH... 7 Sample Segment... 7 Field Descriptions... 8 Patient Identification Segment - PID... 8 Sample Segment Field Descriptions Physician/Client/CC Segment - ZDR Sample Segment Field Descriptions Additional Notes Common Order Segment - ORC Sample Segment Field Descriptions Observation Request Segment - OBR Sample Segment Field Descriptions Additional Notes Observation Result Segment OBX Sample Segment Field Descriptions Additional Notes Notes and Comments Segment - NTE Sample Segment Field Descriptions of 57 P a g e

4 Exception Reporting - ZEX Field Descriptions Forensic Toxicology Order Header - ZTX Field Descriptions Clinical Trials Order Header - ZCT Field Descriptions Cytology Order Header - ZCY Field Descriptions Private Insurance Order Header - ZPI Sample Segment Field Descriptions Segment Template Sample Segment Field Descriptions of 57 P a g e

5 Overview The following record layouts incorporate an HL7 2.x.x standard for the sending of Gamma- Dynacare Laboratories (GDML) Results to various Receiving Systems. This document describes only the outbound laboratory results (reportable GDML laboratory results) and does not specify the distribution methods or the schedules used (if any) for the delivery of these results. The GDML laboratory results are currently formatted into result files using the HL7 2.3 format standard. The message type used is ORU^R01 (HL7 Ver. 2.3 Appendix 4.5 Ancillary Data Reporting, R01 Unsolicited Transmission of an Observation Message ). This message type implies that no message acknowledgement is expected. The GDML laboratory results distribution system will not require an HL7 message acknowledgement. If any part of the HL7 result file(s) are not transmitted or transmitted with errors, the result file(s) will be considered by GDML as NOT being sent. GDML could send an error file for proactive communication if requested. Further rules (not the object of this document) are defined in these cases. The following structure represents the types of segments currently being sent for GDML HL7 results: MSH Message Header segment (One per file sent) { Beginning of message PID Patient Identification segment (can be several) {[NTE]} One or more Notes related to Patient Demographics (PID) {[ZDR]} One or more physicians/clients/cc s associated with order ** {[ZEX]} Exception Reporting associated with PID or OBR or OBX ** {[ZTX]} Forensic Toxicology Order Header associated with order ** {[ZCT]} Clinical Trial Order Header associated with order ** {[ZCY]} Cytology Order Header associated with order {[ZPI]} Private Insurance Order Header associated with order {[ORC]} Order Header (appended) associated with order ORC Common Order (One per MSH) - Winnipeg {OBR Observation Request {[NTE]} One or more notes related to Observation Request {OBX Observation/Result {[NTE]} One or more notes related to Observation Result OBX A second Observation/Result segment within the same Observation Request... } OBR A second OBR segment within the same Patient Identification segment... } PID A second Patient Identification segment within the same Message Header segment... } End of message (marked by end of file or by another Message Header segment) In the structure defined above: Braces, {...} indicate that the contents are mandatory and may be repeated 5 of 57 P a g e

6 Brackets, [...] indicate that the contents is optional Brackets, [{...}] or {[ ]} indicate that the contents is optional and may be repeated 6 of 57 P a g e

7 Structure Governing Rules 1. A result file contains a single Message Header (MSH) segment. 2. At least one PID is mandatory and within each (PID) boundary, there must be at least one OBR and one OBX segment. 3. Within each MSH boundary, several PID segments might be found. 4. The end of a segment is the end of the text line CR (hex 0D) and LF (hex 0A). Minimal Lower Layer Protocol (MLLP) Minimal Lower Layer Protocol (MLLP) is based on a minimalistic OSSI-session layer framing protocol. It is the absolute standard for transmitting HL7 messages. This protocol is required for communications code to be able to recognize the start and the end of each message. These headers and trailers are usually non-printable characters that would not typically be in the content of HL7 messages. Encoding supported in Canada and the U.S. for MLLP is the UTF-8 encoding. The typical structure of an HL7 message being sent via MLLP is described as having four parts: 1. Header - Vertical tab character with a hex value of 0x0B 2. HL7 Message - The message is wrapped using a header and a trailer, immediately followed by a carriage return 3. Trailer - Field separator character with a hex value of 0x1C 4. Carriage Return - A hex value of 0x0D HL7 Standard Message Data fields of varying length and separated by a field separator character are grouped logically into segments. Each segment begins with a 3-character literal or segment identifier field followed by data fields. The data field position within a segment will determine its definition and allowable values. The different types and positioning of segments comprise the HL7 message. In the tables below, if a field has only one component, the component number is not specified. The field and component data types are in conformance with HL7 Version of 57 P a g e

8 Detailed Descriptions of the Segments The following tables describe the segments used in detail, at the field and component level. For column OPT, R is required or mandatory. If empty, it means the field/component might not be represented with a value in the segment. Field Separators - The delimiter character (pipe) is used to indicate the end of a field. Important Segment Notes ** Denotes fields that are defined as place holders only are NOT being populated or supported Denotes fields are supported in Winnipeg LIS only Denotes fields are supported in Ontario LIS only 8 of 57 P a g e

9 Message Header Segment - MSH The Message Header Segment is used to indicate the start of a new message. It contains message level information. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'MSH' 1 R Encoding Characters ^~\& 2 R Sending Application Gamma-Dynacare Medical Laboratories <LIS Application> 3 R Sending Facility GDML 4 Receiving Application Populated with the target application. 5 Receiving Facility Populated with target facility 6 Date & Time of Message CCYYMMDD[hhmmss] (ISO standard) Time is optional. ** 7 Security This is a field place holder only currently it is NOT being populated or R Message Type 1 R Message Type ORU 2 R Trigger Event R01 9 R Message Control ID 16 character format: xxxxxxx , where xxxxxxx reflects the destination of the result file standard formatted GUID 10 R Processing ID P Production, T Training/Debug 11 R Version ID 2.3 ** 12 Sequence Number This is a field place holder only currently it is NOT being populated or ** 13 Continuation Pointer This is a field place holder only currently it is NOT being populated or 9 of 57 P a g e

10 ** 14 Accept Acknowledgement Type ID ** 15 Application Acknowledgement Type ID This is a field place holder only currently it is NOT being populated or This is a field place holder only currently it is NOT being populated or ** 16 Country Code ID This is a field place holder only currently it is NOT being populated or ** 17 Character Set ID This is a field place holder only currently it is NOT being populated or ** 18 Principal Language of Message This is a field place holder only currently it is NOT being populated or Sample Segment MSH ^~\& Gamma-Dynacare Medical Laboratories GDML ORU^R P of 57 P a g e

11 Field Descriptions Segment ID Encoding Characters For the message header segment the value is always coded as MSH The values in this field are special characters that indicate conditions within the HL7 data and are used to assist in parsing the data. The ^ value is used to denote the end of a component or sub field. The ~ value is used to denote the separation of repeating fields. The \ value is used to denote an escape character. The & value is used to denote the end of a sub-component field. Sending Application Sending Facility Receiving Application Receiving Facility Date & Time of Message Because GDML is the source system sending the HL7 data to an Application partnering company, this value is always the company name (Gamma-Dynacare Medical Laboratories LIS Application). Because GDML is the source system sending the HL7 data to an Application partnering company, this value is always the company name (Gamma-Dynacare Medical Laboratories). This could also indicate the GDML lab location. Identify the partner s application by name. Identify the partner s company and location by name. The Date and Time Stamp is in the ISO standard format of century, year, month, day, hours, minutes, and seconds. The time value is optional. Security Message Type Values for this field indicate message data contains one or more laboratory test results. Message Type Trigger Event ORU R01 Message Control ID Processing ID Values for this field indicate message data contains one or more laboratory test results. This is a unique identifier field that identifies this message file being sent. 11 of 57 P a g e

12 Version ID Sequence Number Continuation Pointer Accept Acknowledgement Type ID Application Acknowledgement Type ID Country Code ID Character Set ID Principal Language of Message By setting this flag to the values indicated, the message contents will have been extracted from either GDML s Production or Test database. This field indicates the version number of the HL7 standards being utilized in constructing the content and format of this message. Patient Identification Segment - PID Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'PID' 1 R Set ID Patient ID Starts at 1 for the first PID of each file, Patient ID (Internal) incremented by 1 for each subsequent PID within the message 1 Unique Identifier A unique identifier for the Patient see notes below 2 Version Number Indicates a version for the preceding value if versioning supported 12 of 57 P a g e

13 3 Province Code Value will be 2 character province code 4 Client Reference ID Value will be a unique identifier. Optionally could be used for Client Placer Order ID. 5 Client Type CT = Clinical Trials INS = Insurance OTH = Other 6 Assigning Authority Text field to indicate Assigning Authority 7 Jurisdiction Text field to indicate Jurisdiction 3 1,4 R Patient ID (External) Value will be GDML Lab Code and Accession Number (Format: AB ) Patient identifiers repeating field delimited by ~ 1 R Unique Identifier 9 digit PHIN, 6 Digit MHSC 4 (1,2,3) Assigning Facility Contains sub fields delimited by ^ ex. 4-1 Assigning Authority Ex. CANMB 4-2 Identifier Type Ex. JHN 4-3 Assigning Facility Id Ex. MB 4 1 Patient Alternate ID Physicians Chart # 1 R Unique Identifier 8 alphanumeric characters 4 (1,2,3) Assigning Facility 4-1 Assigning Authority CANMB 4-2 Identifier Type FI assigned by the clinic 4-3 Assigning Facility Id Not populated because Manitoba is in the process of specifying 5 R Patient s Name 1 Family Name Value will be patient s family name 13 of 57 P a g e

14 2 First Name Value will be patient s 1 st name 3 Middle Name/Initial Value will be patient s 2 nd name 6 Mother s Maiden Name Mothers Maiden Name 7 R Date of Birth Value will be patient s date of birth 8 R Sex Value will be patient s sex: CCYYMMDD[hhmmss] (ISO standard) (time optional) M for Male F for Female U for unknown ** 9 Patient Alias This is a field place holder only currently it is NOT being populated or ** 10 Race This is a field place holder only currently it is NOT being populated or 11 Patient Address 1 Address Line 1 Value will be patient s Street Address 2 Address Line 2 Value will be patient s Apartment/ Unit # 3 Address Line 3 Value will be patient s City 4 Province Value will be patient s Province Code - 2 character e.g. ON 5 Postal Code Value will be patient s Postal Code (no spaces) 6 Country Country ** 12 Country Code This is a field place holder only currently it is NOT being populated or 13 Patient Home Phone # Value will be patient s Home Phone Number Area Code 3 digits, Exchange 3 digits, Number 4 digits ** 14 Patient Alternate Phone # This is a field place holder only currently it is NOT being populated or ** 15 Primary Language This is a field place holder only currently it is NOT being populated or ** 16 Marital Status This is a field place holder only currently it is NOT being populated or 14 of 57 P a g e

15 ** 17 Religion This is a field place holder only currently it is NOT being populated or ** 18 Patient Account Number This is a field place holder only currently it is NOT being populated or ** 19 SSN Number of Patient This is a field place holder only currently it is NOT being populated or ** 20 Driver s License Number This is a field place holder only currently it is NOT being populated or ** 21 Mother s Identifier This is a field place holder only currently it is NOT being populated or ** 22 Ethnic Group This is a field place holder only currently it is NOT being populated or ** 23 Birth Place This is a field place holder only currently it is NOT being populated or ** 24 Multiple Birth Indicator This is a field place holder only currently it is NOT being populated or ** 25 Birth Order This is a field place holder only currently it is NOT being populated or ** 26 Citizenship This is a field place holder only currently it is NOT being populated or ** 27 Veterans Medical Status This is a field place holder only currently it is NOT being populated or ** 28 Nationality Code This is a field place holder only currently it is NOT being populated or ** 29 Patient Death Date and Time This is a field place holder only currently it is NOT being populated or ** 30 Patient Death Indicator This is a field place holder only currently it is NOT being populated or Sample Segment PID ^^ON PATIENT NAME M PATIENT ADDRESS^PATIENT ADDRESS LINE 2^ONTARIO^ON Field Descriptions Segment ID Set ID Patient ID Patient ID (External) For the patient identification segment the value is always coded as PID. This field value is initialized to 0 when the MSH segment is created. It then starts at 1 for the first PID of each message file and is then incremented by 1 for each subsequent PID within the message. This field is separated into sub-fields or components. 15 of 57 P a g e

16 Unique Identifier Version Number Province Code Client Reference ID For Ontario the patient s Health Card # value is used. For other regions that may not have a Health Card system, the patient s Driver s License could be substituted. This field value refers to the Unique Identifier field. This field value is the two-character Province Code. The US state code could be substituted when applicable. This field value will be a unique identifier code This field value is used to indicate the Client Type: Client Type CT = Clinical Trials INS = Insurance OTH = Other Assigning Authority Jurisdiction Patient ID (Internal) Unique Identifier Assigning Facility Assigning Authority Identifier Type Assigning Facility Id Patient Alternate ID Unique Identifier This text field indicates the Assigning Authority for the Client Type This text field indicates the Jurisdiction for the Client Type This field value will be the GDML Lab Number that resulted the tests or the GDML Accession Number that identifies the Lab and a sequential accession (requisition) number (Format: AB ). Unique Identifier Assigning Facility Assigning Authority Identifier Type Assigning Facility Id Physicians chart number 8 alphanumeric characters Assigning Facility Assigning Authority 16 of 57 P a g e

17 Identifier Type Assigning Facility Id Patient s Name Family Name First Name Middle Name/Initial Mother s Maiden Name Date of Birth Sex Patient Alias Race Patient Address Address Line 1 This field is separated into sub-fields or components. This field value will be patient s family name This field value will be patient s 1 st name This field value will be patient s 2 nd name or initial This field value will be patient s Birth Date is in the ISO standard format of century, year, month, day, hours, minutes, and seconds. Format: CCYYMMDD[hhmmss] (ISO standard). The time value is optional. This field value will be patient s Sex. Values can be M for Male, F for Female or U for unknown (not relevant to the tests being performed). This field is separated into sub-fields or components. This field value will be the patient s Street Address Address Line 2 This field value will be the patient s Unit or Apartment # Address Line 3 Province Postal Code Country Country Code This field value will be the patient s City Name This field value is the two-character Province Code. The US state code could be substituted when applicable. This field value is the six-character Postal Code. The US ZIP code could be substituted when applicable. Country in full text 17 of 57 P a g e

18 Patient Home Phone # Patient Alternate Phone # Primary Language Marital Status Religion Patient Account Number SSN Number of Patient Driver s License Number Mother s Identifier Ethnic Group Birth Place Multiple Birth Indicator Birth Order Citizenship Veterans Medical Status Nationality Code Patient Death Date and Time 18 of 57 P a g e

19 Patient Death Indicator 19 of 57 P a g e

20 Physician/Client/CC Segment - ZDR Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZDR' 1 R Set ID ZDR Starts at 1 for the first ZDR of a PID, incremented by 1 for subsequent ZDR s within the PID grouping. 2 R Segment Type C client information, Physician P physician information, CC Courtesy Copy physician information 1 R Physician / Client # Value will be the Physician s ID Number or Client s ID Number Value will be the client id Value will be the physician ID number CC ). (if ZDR.2= C ) (if ZDR.2= P or 2 R Alternate Address # Alternate address for the ID code in 3.1 field. 3 Regulatory Body Type Regulatory Body Type (i.e. CPSO, Pharmacy, NP, MW, etc) 4 Regulatory Body ID Regulatory Body ID: CPSO #, Pharmacy ID, NP #, Midwife #, etc) Physician Name 1 R Name Physician, Client or Company name 2 Last Name Physician Last 3 Middle Name Physician Middle Name Physician Address 1 Address Line 1 Value will be Street Address 2 Address Line 2 Value will be Unit # 20 of 57 P a g e

21 3 Address Line 3 Value will be City 4 Province Value will be Province Code - 2 character e.g. ON 5 Postal Code Value will be Postal Code (no spaces) 6 Telephone # Value will be Phone Number Area Code 3 digits, Exchange Number 3 digits, 4 digits 9 Slot Code 3 characters 10 Courier Routes 1 Courier Route 1 3 characters 2 Courier Route 2 3 characters 3 Courier Route 3 3 characters Sample Segment ZDR 1 P PHYSICIAN NAME STREET NAME^CITYNAME^ON^K1A1A ZDR 2 CC PHYSICIAN NAME CLINIC NAME^CLINIC ADDRESS^CLINIC CITY^ON^K1A1A of 57 P a g e

22 Field Descriptions Segment ID Set ID ZBR For the patient identification segment the value is always coded as ZDR. This field value is initialized to 0 when the PID segment is created. Segment Type Physician Physician / Client # Alternate Address # Regulatory Body Type Regulatory Body ID Physician Name Name Last Name Middle Name Physician Address Address Line 1 This field is separated into sub-fields or components. This field value will be the Physician s or Clients ID Number. This field value is a number depicting the sequence number (index) of an alternate address. This field value represents the Regulatory Body Type: CPSO, Pharmacy, NP, MW, etc. This field value represents the Regulatory Body ID code: CPSO #, Pharmacy ID, Nurse Practitioner #, Midwife #, etc. This field is separated into sub-fields or components. Physician s 1 st name, Client or Company name Physician s Last Name Physician s Middle Name This field is separated into sub-fields or components. This field value will be the Street Address Address Line 2 This field value will be the Suite / Unit # Address Line 3 Province Postal Code Telephone # This field value will be the City This field value will be the 2-character province code. The US State code could be used when applicable. This field value will be the 6-character Canadian Postal code. The US Postal Zip code could be used when applicable. This field value will be the Physician s telephone number comprised of Area Code 3 digits 22 of 57 P a g e

23 Exchange Number 3 digits 4 digits Slot Code Courier Routes Courier Route 1 Courier Route 2 Courier Route 3 This field value is an internal GDML code for routing. This field is separated into sub-fields or components. This field value is an internal GDML code for routing. This field value is an internal GDML code for routing. This field value is an internal GDML code for routing. Additional Notes As of the time of this version, the ZDR segment will only contain CC data, which is intended to be received by the CC d physician or client. Ordering physicians, if receiving HL7 files will not reflect the CC d physicians at this time. This segment will not be seen in any HL7 files processed by GDML s DIS system. This segment is used to identify where a client associated with an order is different than the physician. Likewise, if there are CC s clients/physicians associated with an order, it is identified in this segment. The recipient of the data file can be any of the clients identified in the ZDR segments. 23 of 57 P a g e

24 Common Order Segment - ORC Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ORC' 1 R Order Control Value must be NW, RO, XO, CA, RV Value NW new test request Value RO add test request to order Value XO update test request Value CA cancel test request Value RV demographics updated causing entire order to be moved from history to ready status ** 2 Placer Order Number This is a field place holder only currently it is NOT being populated or ** 3 Filler Order Number This is a field place holder only currently it is NOT being populated or 4 1,2 R Patient ID (External) Placer Group Number GDML Lab Number (Format: AB ) or Accession Number 1 R Unique Id Accession Number 2 R Filler Application Id GDMLHL7Export 5 Order Status F Final R Revised Final O - Interim ** 6 Response Flag This is a field place holder only currently it is NOT being populated or ** 7 Quantity/Timing This is a field place holder only currently it is NOT being populated or ** 8 Parent Order This is a field place holder only currently it is NOT being populated or 9 R Date/time of transaction Date and time the current transaction entered the ordering application. Format CCYYMMDDHHMMSS-ZZZZ 24 of 57 P a g e

25 24 1,2,3,4,5,6 Ordering physician address 1 Street Address 2 Other Designation Location name 3 City 4 Province 5 Postal Code 6 Country Sample Segment ORC NW IN Field Descriptions Segment ID Order Control Placer Order Number Filler Order Number Patient ID (External) For the Additional Patient Identification segment the value is always coded as ORC. Value must be NW, RO, XO, CA, RV GDML Lab Number (Format: AB ) or Accession Number Placer Group Number Unique Id Accession # Filler Application Id System that assigned the accession # Order Status The status of the order. F Final R Revised Final 25 of 57 P a g e

26 O - Interim Response Flag Quantity/Timing Parent Order Date/time of transaction Date and time the current transaction entered the ordering application. Format CCYYMMDDHHMMSS-ZZZZ Ordering physician address Street Address Other Designation City Province Street name and number Local description City Province code Postal Code Country 26 of 57 P a g e

27 Observation Request Segment - OBR Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'OBR' 1 R Set ID OBR Starts at 1 for the first OBR of a PID group and Incremented by 1 for each subsequent OBR within the PID grouping. 2 1 Placer Order Number 1 ID Populated with vendor/emr order number Filler Order Number 1 ID Test code followed by a dash and a unique number. The unique number is unique within the context of the PID 2 Application Id R Universal Service ID 1 GDML Test Code 2 Test Name The test name or Loinc code if available. 3 MOH Test Code 4 Department Department where test was performed. Ex: CHMISTRY, HEMATOLOGY, HISTOLOGY. 5 R Priority R Regular, S Stat 6 R Requested Date/Time CCYYMMDD[hhmmss] ISO Standard (time optional) 7 R Collection Date/Time CCYYMMDD[hhmmss] ISO Standard (time optional) ** 8 Observation End Date/Time CCYYMMDD[hhmmss] ISO Standard (time optional) This is a field place holder only currently it is NOT being populated or 27 of 57 P a g e

28 9 Collection Volume ** 10 Collector Identifier This is a field place holder only currently it is NOT being populated or 11 Specimen Action Flag Always N ** 12 Danger Code This is a field place holder only currently it is NOT being populated or ** 13 Relevant Clinical Information 14 R Specimen Received Date and Time This is a field place holder only currently it is NOT being populated or CCYYMMDDHHMMSS-ZZZZ Century, Year, Month, Day, Hours, Minutes, Seconds GMT offset ISO Standard ** 15 Specimen Source This is a field place holder only currently it is NOT being populated or R Ordering Physician 1 Physician Unique Identifier 2 Physician Name Family Name 3 Physician s OHIP # If different from component 1 First Initial 17 Order Call Back Phone # Physicians phone number ** 18 Placer Field 1 This is a field place holder only currently it is NOT being populated or ** 19 Placer Field 2 This is a field place holder only currently it is NOT being populated or ** 20 Filler Field 1 This is a field place holder only currently it is NOT being populated or ** 21 Filler Field 2 This is a field place holder only currently it is NOT being populated or 22 R Resulted Date/Time CCYYMMDD[hhmmss] ISO Standard ** 23 Charge to Practice This is a field place holder only currently it is NOT being populated or ** 24 Diagnostic Service Section ID This is a field place holder only currently it is NOT being populated or 28 of 57 P a g e

29 25 Result Status C result has been amended and approved (final) F result is final (approved) O default ** 26 Parent Result This is a field place holder only currently it is NOT being populated or ** 27 Quantity/Timing This is a field place holder only currently it is NOT being populated or ,14 Result Copies to 1 ID Number Repeatable field delimited by ~ 2 Family Name 3 Given Name 14 Assigning Facility 29 Parent Number Refers to the parent OBR field 1 ** 30 Transportation Mode This is a field place holder only currently it is NOT being populated or ** 31 Reason for Study This is a field place holder only currently it is NOT being populated or ** 32 Principle Result Interpreter This is a field place holder only currently it is NOT being populated or ** 33 Assistant Result Interpreter This is a field place holder only currently it is NOT being populated or ** 34 Technician This is a field place holder only currently it is NOT being populated or ** 35 Transcriptionist This is a field place holder only currently it is NOT being populated or ** 36 Scheduled Date & Time This is a field place holder only currently it is NOT being populated or ** 37 # of Sample Containers This is a field place holder only currently it is NOT being populated or ** 38 Transport Logistics of Collected Containers This is a field place holder only currently it is NOT being populated or ** 39 Collector s Comment This is a field place holder only currently it is NOT being populated or ** 40 Transport Arrangement Responsibility This is a field place holder only currently it is NOT being populated or 29 of 57 P a g e

30 ** 41 Transport Arranged This is a field place holder only currently it is NOT being populated or ** 42 Escort Required This is a field place holder only currently it is NOT being populated or ** 43 Planned Patient Transport This is a field place holder only currently it is NOT being populated or Sample Segment OBR 1 HRPT^HEPATITIS TESTING^N/A A R N ^DR BONES TESTS^ of 57 P a g e

31 Field Descriptions Segment ID Set ID OBR Placer Order Number For the Observation Request segment the value is always coded as OBR. This field value is initialized to 0 when the PID segment is created. It then starts at 1 for the first OBR of each message file and is then incremented by 1 for each subsequent OBR within the message. This field is separated into sub-fields or components. ID Clinic s EMR accession # Filler Order Number ID This field is separated into sub-fields or components. The test code, followed by a dash and a unique identifier. The unique identifier is unique within the context of the PID. Eg. 033-N1013B : the test code is 033 and the unique number is N1013B Eg N1003A: the test code is and the unique number is N1003A Application Id Universal Service ID GDML Test Code Test Name MOH Test Code This field is separated into sub-fields or components. This field value will be GDML Internal Test Code. This field value will be GDML Internal Test Code or Loinc code if available. This field value will be Ministry of Ontario (OHIP) Test Code. If the MOH Test Code is N/A or N/A A, it can be considered: missing not applicable invalid. OHIP and MOH refer to Ontario Health Insurance Plan and Ontario Ministry of Health. 31 of 57 P a g e

32 Department This field value will be GDML Department where test was performed. For Department here are some examples of valid values: CHEMISTRY IMMUNOASSAY MICROBIOLOGY TEST(S) TO FOLLOW REFERRED TEST(S) Priority This field value will be: R for Regular, S for Stat (High Priority) Requested Date/Time This field value will be the requisition request date and time in the ISO Date/Time standard format of century, year, month, date, hours, minutes, seconds (CCYYMMDD [hhmmss]). Time value is optional. Collection Date/Time Observation End Date/Time Collection Volume Collector Identifier Specimen Action Flag Danger Code Relevant Clinical Information Specimen Received Date and 32 of 57 P a g e

33 Time Specimen Source Ordering Physician Physician Physician Name Family Name Physician s OHIP # First Initial Order Call Back Phone # Placer Field 1 Placer Field 2 Filler Field 1 Filler Field 2 Resulted Date/Time Charge to Practice Diagnostic Service Section ID Result Status Parent Result Quantity/Timing Populated with the parent OBR Field 3-1. Typically used for complex results wherein a test may have a parent test. 33 of 57 P a g e

34 Result Copies to ID Number Family Name Given Name Assigning Facility Parent Number Transportation Mode Reason for Study Principle Result Interpreter Assistant Result Interpreter Technician Transcriptionist Scheduled Date & Time # of Sample Containers Transport Logistics of Collected Containers Collector s Comment Transport Arrangement Responsibility This enables the OBR to refer back to a parent OBR. This field will be unique within a given PID segment. 34 of 57 P a g e

35 Transport Arranged Escort Required Planned Patient Transport Additional Notes If the OBR segment has several components (OBX segments) each OBX segment should be checked for an Abnormal Flag. 35 of 57 P a g e

36 Observation Result Segment OBX Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'OBX' 1 R Set ID OBX Starts at 1 for the first OBX of an OBR, increments by 1 for subsequent OBX segment within the OBR grouping. 2 Value Type CE Code Entry (used for internal paragraph table codes) R Observation Identifier DT Date ED Encapsulated Data FT Formatted Text (Display) NM Numeric SN Structured Numeric ST String Data (Text) TM Time TS Time Stamp (Date & Time) TX Text Data (Display) 1 GDML Test Code This field value will be the GDML test code 2 Test Component Sequence # If the test is resulted with multiple components, then this value will be initialized to 1 and incremented sequentially for each subsequent component for the test in field 3.1 (GDML test code). 3 Test Name Test name or loinc code if available. 4 Alt Ident code LIS Testcode 3 digit 5 Alt Ident Txt LIS test desc 6 Alt Ident Coding GDML 4 Observation Sub-Id The sequence number of the test 36 of 57 P a g e

37 5 R Observation Results For the FT type, the \.br\~ string is used to denote the end of a line for presentation purposes (printable or displayable line). 6 Units 7 Reference range The \.br\~ string is used to denote the end of a line for presentation purposes (printable or displayable line), when a multiple line description exists for the reference range. 1 Structured reference range (legacy) This field will always contain two values (numeric or text) separated with a dash (-). 2 Formatted reference range This field should be treated always as a formatted text. 3 Structured reference range Low Value This represents the low reference points used to mathematically determine if a result is abnormal. This field value & the next field value replace the values in field Structured reference range High Value This represents the high reference points used to mathematically determine if a result is abnormal. 8 Abnormal Flag N Normal This field value & the previous field value replace the values in field 7.1. A Abnormal L Abnormal Low H Abnormal High LL Abnormal Critically Low HH Abnormal Critically High Blank or null - result cannot be interpreted as normal or abnormal ** 9 Probability This is a field place holder only currently it is NOT being populated or 10 Observation Result Status (legacy) F Final R Revised P Preliminary blank indicates that OBX.11 should be used to determine status 11 R Observation Result Status F Final Field to be kept and populated for legacy applications using this field to determine result status C Changed or Revised P Preliminary ** 12 Date Last Observed Normal Values CCYYMMDD[hhmmss] ISO Standard (time optional) This is a field place holder only currently it is NOT being populated or 37 of 57 P a g e

38 ** 13 User Defined Access Checks CCYYMMDD[hhmmss] ISO Standard (time optional) This is a field place holder only currently it is NOT being populated or 14 Date & Time of Observation Date and time of the observation. ** 15 Producer s ID This is a field place holder only currently it is NOT being populated or ** 16 Responsible Observer This is a field place holder only currently it is NOT being populated or ** 17 Observation Method This is a field place holder only currently it is NOT being populated or Sample Segment OBR ^HISTOLOGY^L720A R N ^P PATIENT NAME OBX 1 ST 7201&01^TISSUE (SITE) 1 F OBX 2 ST 7201&09^SUMMARY OF HISTORY 1 F OBX 3 ST 7201&13^CLINICAL DIAGNOSIS 1 F OBX 4 ST 7201&17^GROSS 1 F OBX 5 ST 7201&18^GROSS 1 F OBX 6 ST 7201&19^GROSS 1 F OBX 7 ST 7201&27^MICROSCOPIC 1 F OBX 8 ST 7201&28^MICROSCOPIC 1 F OBX 9 ST 7201&47^DIAGNOSIS 1 F OBX 10 ST 7201&48^DIAGNOSIS 1 F OBX 11 FT 7201^HISTOLOGY \.br\~tissue (SITE): Left postauricular area\.br\~summary OF HISTORY: Small, ulcerated, 3 mm pa\ pule\.br\~clinical DIAGNOSIS: BCCa\.br\~GROSS: The specimen consists of a beige-\ tan piece\.br\~measuring 8 mm in greatest dimension and\.br\~fragment(s). Embedded in toto.\.br\~microscopic: Skin biopsy left po\ stauricular area\.br\~sections of the skin biopsy show basal cell carcinoma\.br\~with a \ 38 of 57 P a g e

39 superficial multicentric growth pattern.\.br\~arising from the undersurface of the epidermis there are\.br\~flattened nests of basa\ loid keratinocytes showing\.br\~peripheral palisading.\.br\~diagnosis: Skin biopsy l\ eft postauricular area: basal cell\.br\~carcinoma, superficial multicentric type\.br\~pathologist: DR. R. PROKOPETZ M.D.\.br\~(si\ gnature on file) F Field Descriptions Segment ID Set ID OBX Value Type For the Observation / Result segment the value is always coded as OBX. Starts at 1 for the first OBX of an OBR, incremented by 1 for each subsequent OBX. This field value will be: NM for Numeric ST for String (Text) FT for Formatted text (string) CE for Coded Entry (used for internal paragraph table codes) Observation Identifier GDML Test Code Test Component Sequence # Test Name This field is separated into sub-fields or components. This field value will be GDML Test Code If the test is resulted with multiple components, then this value will be initialized to 1 and incremented sequentially for each subsequent component for the GDML test code. This field value will be Test name or loinc code if available. Alt Ident code Alt Ident Txt Alt Ident Coding Observation Sub- Id Observation Results This field value will be a sequence number of the observation for the test. This field value may be numeric, or text (one word positive/negative) or several lines of text. For the FT type, the \.br\~ string is used to denote 39 of 57 P a g e

40 the end of a line for presentation purposes (printable or displayable line). These adjoined text field lines are built by an internal process to construct the single text field from many individual text fields based on the number of component test fields related to the test code. Units Reference range Structured reference range (legacy) Formatted reference range Structured reference range Low Value Structured reference range High Value This field is separated into sub-fields or components. Represents low and high reference points to mathematically determine if a result is abnormal. This field value should be treated always as a formatted text. Each line is coded as a repeat component. Text formatting commands might be included (e.g. \.br\~ for a new line). Represents the low reference points used to mathematically determine if a result is abnormal. Represents the high reference points used to mathematically determine if a result is abnormal. Abnormal Flag This field value will be whether or not the results of the test were normal or not. Values can be either: N Normal A Abnormal L Abnormal Low H Abnormal High LL Abnormal Critically Low HH Abnormal Critically High Blank or null - result cannot be interpreted as normal or abnormal Probability Observation Result Status This field value will indicate the status of the result observation status and can be: 40 of 57 P a g e

41 (legacy) F for Final R for Revised P Preliminary blank - indicates that OBX.11 should be used to determine status Observation Result Status This field value will indicate the status of the result observation status and can be: F for Final C for Changed or Revised P Preliminary Date Last Observed Normal Values User Defined Access Checks Date & Time of Observation Producer s ID Responsible Observer Observation Method Additional Notes Units field might be empty in cases were no U/M is defined for a certain result or when the result is of qualitative nature (e.g. Positive, NEG or text). Components of a test code are sent as OBX segments using GDML Test Code (OBX HL7 field 3) and sign followed by the component number and description (please refer to result samples section). The result can consist of several lines of text. In this case, field no. 5 (Observation Results) might consist of repeat fields with a formatted command new line or end of displayable text subfield( \.br\~ ) is included at the end of each line. In the case when OBR s test description is the same as the first OBX s test description (OBR field 4 component 2 = OBX field 3 component 2), the repeated string should be displayed only once. 41 of 57 P a g e

42 42 of 57 P a g e

43 Notes and Comments Segment - NTE Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be ' NTE 1 Set ID NTE Starts at 1 for the first NTE, increments by 1 for each subsequent NTE record within a PID, OBR or OBX segment grouping. 2 R Source of Comment L 2 R Comment Can be Remarks for Patient Demographics if following PID segments or other information related to the test result if following OBR or OBX segments. 3 R Comment Comment code 4 R Comment 2 Can be Remarks for Patient Demographics if following PID segments or other information related to the test result if following OBR or OBX segments. Sample Segment NTE 1 FAX IF POSITIVE FAX#: NTE Field Descriptions Segment ID Set ID NTE For the Notes and Comments segment the value is always coded as NTE. Starts at 1 for the first NTE, incremented by 1 for each subsequent note or comment line within a PID, OBR or OBX segment group. Source of Comment Comment This field value can be Remarks for Patient Demographics, if following a PID segment. This field value can be other information related to the test result, if following OBR and / or OBX segments. 43 of 57 P a g e

44 44 of 57 P a g e

45 Exception Reporting - ZEX This segment is not currently supported by Winnipeg LIS. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZEX' ** 1 R Set ID ZEX Starts at 1 for the first ZEX, increments by 1 for each subsequent ZEX record within a PID, OBR or OBX segment grouping. ** 2 R Exception Code ** 3 R Exception Text The Exception Text relating to the Exception Code ** 4 O PID ID The PID unique identifiers that the exception is reported for. ** 5 O OBR ID The OBR unique identifiers that the exception is reported for. ** 6 O OBX ID The OBX unique identifiers that the exception is reported for. Field Descriptions Segment ID Set ID ZEX Exception Code Exception Text PID ID OBR ID For the Exception Reporting segment the value is always coded as ZEX. 45 of 57 P a g e

46 OBX ID 46 of 57 P a g e

47 Forensic Toxicology Order Header - ZTX This segment is not currently supported by Winnipeg LIS. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZTX' 1 R Location This is a field place holder only currently it is NOT being populated or 2 O Requisition Number This is a field place holder only currently it is NOT being populated or 3 R Client Reference Number This is a field place holder only currently it is NOT being populated or 4 R Toxicology Collection Site This is a field place holder only currently it is NOT being populated or 5 R Toxicology Company Number This is a field place holder only currently it is NOT being populated or 6 R Toxicology Company Name This is a field place holder only currently it is NOT being populated or 7 R Collector s Name This is a field place holder only currently it is NOT being populated or 8 Collection Site Name This is a field place holder only currently it is NOT being populated or 9 R Collection Site Address 1 This is a field place holder only currently it is NOT being populated or 10 R Collection Site Address 2 This is a field place holder only currently it is NOT being populated or 11 R Collection Site City This is a field place holder only currently it is NOT being populated or 12 R Collection Site Province This is a field place holder only currently it is NOT being populated or 13 R Collection Site Postal Code This is a field place holder only currently it is NOT being populated or 14 R Toxicology Secondary Specimen ID # This is a field place holder only currently it is NOT being populated or 47 of 57 P a g e

48 Field Descriptions Segment ID Location Requisition Number Client Reference Number Toxicology Collection Site Toxicology Company Number Toxicology Company Name Collector s Name Collection Site Name Collection Site Address 1 Collection Site Address 2 Collection Site City Collection Site Province Collection Site Postal Code Toxicology Secondary Specimen ID # For the Exception Reporting segment the value is always coded as ZEX. 48 of 57 P a g e

49 49 of 57 P a g e

50 Clinical Trials Order Header - ZCT This segment is not currently supported by Winnipeg LIS. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZCT' ** 1 R Location This is a field place holder only currently it is NOT being populated or ** 2 O Requisition # This is a field place holder only currently it is NOT being populated or ** 3 R Study # This is a field place holder only currently it is NOT being populated or ** 4 R Investigator Site This is a field place holder only currently it is NOT being populated or ** 5 R Subject # This is a field place holder only currently it is NOT being populated or ** 6 R Clinical Trial Subject Initials This is a field place holder only currently it is NOT being populated or ** 7 R Screening # This is a field place holder only currently it is NOT being populated or ** 8 R Randomization # This is a field place holder only currently it is NOT being populated or ** 9 R Visit # This is a field place holder only currently it is NOT being populated or ** 10 R Visit Name This is a field place holder only currently it is NOT being populated or ** 11 R Visit Type This is a field place holder only currently it is NOT being populated or Field Descriptions Segment ID Location For the Clinical Trial Order Header segment the value is always coded as ZCT. 50 of 57 P a g e

51 Requisition # Study # Investigator Site Subject # Clinical Trial Subject Initials Screening # Randomization # Visit # Visit Name Visit Type Cytology Order Header - ZCY This segment is not currently supported by Winnipeg LIS. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZCY' 51 of 57 P a g e

52 ** 1 R Location This is a field place holder only currently it is NOT being populated or ** 2 O Requisition # This is a field place holder only currently it is NOT being populated or ** 3 R Pathologist This is a field place holder only currently it is NOT being populated or Field Descriptions Segment ID Location Requisition # Pathologist For the Cytology Order Header segment the value is always coded as ZCY. 52 of 57 P a g e

53 Private Insurance Order Header - ZPI This segment is not currently supported by Winnipeg LIS. Field # SubField # Optional or Require d Name Comments 0 R Segment ID Value will be 'ZPI' 1 R Ticket The bar code number that is pre-printed on every insurance lab authorization form 2 O Policy # The insurance policy number as assigned by each client. 3 R Examiner Code The Paramedical company that performed the collection of the sample. 4 R Insurance Type The product line of the policy. 5 R Insurance Amount The dollar amount associated with the policy. 6 R Date/Time last Food Taken The date and time when the applicant last had food before the collection of samples. ** 7 R Insurance Agent This is a field place holder only currently NOT being populated or ** 8 R Agent Province Code This is a field place holder only currently NOT being populated or 9 R Examining Company The company name associated with the examiner code. 10 R Examining Province Code The province where the paramedical service was provided. 11 R Specimen Temperature The temperature of the urine just after the collection process. 12 R Mensus Flag Current mensus at collection time. 53 of 57 P a g e

54 Sample Segment ZPI EXAMON GRP:LIFE AGENT # ON EXAMONE ON 38 Field Descriptions Segment ID Ticket Policy # Examiner Code Insurance Type Insurance Amount Date/Time last Food Taken Insurance Agent Agent Province Code Examining Company Examining Province Code Specimen Temperature Mensus Flag For the Private Insurance segment the value is always coded as ZPI. The bar code number that is pre-printed on every insurance lab authorization form. The insurance policy number as assigned by each client. The Paramedical company that performed the collection of the sample. The product line of the policy. The dollar amount associated with the policy. The date and time when the applicant last had food before the collection of samples. The company name associated with the examiner code. The province where the paramedical service was provided. The temperature of the urine just after the collection process. Current mensus at collection time. 54 of 57 P a g e

55 Segment Template Field # SubField # Optional or Require d Name Comments 55 of 57 P a g e

56 Sample Segment Field Descriptions 56 of 57 P a g e

57 57 of 57 P a g e