Pathology Bounded Code List (PBCL) Version for Primary Care Pathology Report Messages

Transcription

1 Release Note Pathology Bounded Code List (PBCL) Version for Primary Care Pathology Report Messages April 2016 Release 1 Copyright 2016, Health and Social Care Information Centre.

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3 CONTENTS 1. Introduction 1 2. Scope 1 3. Publication Overview Contents Summary of Labset and PBCL files 2 4. Changes in this Release 3 5. Proposed deletions for the next Release 3 6. Timetable for implementation 4 8. PBCL Governance Changes 4 7. Requests for additions and changes 5 APPENDIX A 6 Proposed Deletions from the PBCL for the release (October 2016) 6 APPENDIX B 6 Overview of the Labsetv1033.txt file structure 6

4 1. Introduction This document describes the content of Version of the Pathology Bounded Code List (PBCL) for use within NHS primary care pathology report messaging. This document also provides the outline timetable for implementation of PBCL Version for NHS primary care. The new content within this release has undergone reviews by the Primary Care Pathology (information standards) National User Group and has also had an open online review. This release was approved by the Primary Care Pathology National Advisory Group for publication. 2. Scope This scope of this release of the PBCL applies to all versions of the MEDRPT laboratory service report message. The PBCL standard terms and codes are Read Clinical Terms from _ as the April 2016 release. Further information can be found here: Terminology data files and supporting information can be obtained (on registration) via the Technology Reference Data Update Distribution Service (TRUD) maintained by the UK Terminology Centre (UKTC): 1

5 3. Publication Overview PBCL Version contains 7 files, including this one: 1. A ReadMe file (TXT) providing a very short overview of PBCL Release contents 2. Release Note (PDF). This document has been updated from previous Releases to fully describe the Release contents. 3. Labsetv1033 (TXT). This file contains all PBCL Read V2 terms and codes and their mapping to CTV3. 4. Labsetv1033 (CSV). This file contains the same content as Labsetv1033.txt, excluding all information related to mapping across Read terminology versions. 5. PBCL_ (CSV)This file contains the same content as Labsetv1033(CSV), with the addition of recommended units of measure and recommended result values per test (this information was published in previous releases within the PBCL_Supplementary_File). 6. PBCL_DeltaAdditions_ (CSV). New in this Release. This identifies the Read codes and terms that have been newly added in this Release. 7. LSR April 2016 (PDF) This is a list of units of measure standard terms and abbreviations recommended for use by the Royal College of Pathologists. Comment [KR1]: The two Labsetv1033 files are NOT INCLUDED in this open review pack Comment [KR2]: This file is included in the open review pack in.xls (EXCEL) format for review purposes only. If acceptable, this file is proposed to replace Labsetv<x>.csv files in future PBCL releases. Comment [LS3]: This file is currently under review within the Royal College of Pathologists and is not included within this review pack. 3.1 Contents Summary of Labset and PBCL files Table 1 provides a summary overview of content within this PBCL Release s Labsetv1033.txt and PBCL_ csv files. 2 Column Labsetv1033.txt PBCL_ csv Comment FOURBYTE_READ_CODE FOURBYTE_TERM V2_READ_CODE V2_TERM_CODE V2_TERM V3_READ_CODE V3_TERM_ID V3_TERM PBCL Metadata For Information Only KEY COMMENTS REPORT REQUEST BATTERY

6 Column Labsetv1033.txt PBCL_ csv Comment LEVEL TEST RATIO BOOLEAN TEXT STATUS RELEASE_DATE REC_UNITOFMEAS Recommended Unit of Measure New in V1.033 REC_VALUES Recommended Values New in V1.033 DATA_CONV_INDEX Data Conversion Index New in V1.033 Table 1. Summary of content in Labsetv1033.txt and Labsetv1033.csv files A summary of the information contained in Labsetv1033.txt is in Appendix B. 4. Changes in this Release Comment [LS4]: This section would only appear in future (post-april) releases if the new file approach is seen as useful through this consultation. All PBCL code and term additions for this Release are listed in the PBCL_DeltaAdditions_ csv file. All new codes added in this version have a date of The codes can be filtered in the file on this basis The Delta file includes a summary of the rationale provided by the requestor for each new code. 5. Proposed deletions for the next Release PBCL term and code deletions proposed for the next Release are listed, with rationale, in Appendix A. 3

7 6. Timetable for implementation PBCL Implementation Timetable (6 weeks implementation from publication) Date of release of this new version 8 th April 2016 Earliest date on which GP system suppliers may implement this new version in live GP Practice sites Latest date by which GP system suppliers must implement this new version in live GP Practice sites 22 nd April rd June 2016 Earliest date on which laboratories may implement this new version 4 th June 2016 Latest date on which laboratories must implement this new version 4 th July 2016 NMAS to implement the new version of the PBCL 22 nd April 2016 Please ensure you are registered for the PBCL pack on TRUD to receive a notification of posting. 7. Impact on Pathology Reporting of Read Code Withdrawal To view the notices and to see the latest information on the phasing out of Read v2 and Read v3 please go to the Read Codes webpage on the HSCIC UKTC site 8. PBCL Governance Changes The new PBCL governance established by HSCIC and NHS England is now in place to oversee PBCL releases. NHS England, The Royal College of Pathologists and the British Medical Association / Royal College of General Practitioners Joint GP IT Committee provide governance leadership roles. Increased user engagement for the national development of primary care pathology information standards has also been implemented. An online discussion forum is available to raise queries and respond to discussion threads. Participation in the Primary Care Pathology (information standards) National User Group is open to all and can be requested by ing us at diagnosticsdata@hscic.gov.uk. The User Group meets monthly for one hour online. For any queries about governance or user engagement, please contact diagnosticsdata@hscic.gov.uk. 4

8 7. Requests for additions and changes Terminology requests should be made via the web-based Request Submission Portal at: You can then select the Product ( Read Codes ) to which the request relates. You can also go directly to the Product page: Please check the PBCL box to distinguish the request from general Read requests. Important Note: mycodeplace, the previous request utility, is no longer in use and all outstanding requests have been migrated to the new Portal. Any enquiries regarding requests should be directed to the UKTC Help Desk at: information.standards@hscic.gov.uk 5

9 APPENDIX A Proposed Deletions from the PBCL for the release (October 2016) READ CODE READ TERM REASON FOR PBCL REMOVAL 44TB0 HbA1c (diagnostic refrn range) IFCC. 44TB1 HbA1c (monitoring ranges) This code was introduced during the transition from DCCT to IFCC methods and needed to be replaced with a term that clearly indicated This code was introduced during the transition from DCCT to IFCC methods and needed to be replaced with a term that clearly indicated IFCC. APPENDIX B Overview of the Labsetv1033.txt file structure All new codes added in this version have a date of The codes can be filtered in the file on this basis. The first row (included in the total) is a header giving the name of each field within each record. Each record relates to an individual concept that identifies a laboratory investigation, and contains 20 pipe delimited fields. The record contains codes and their associated 30 character terms (many of which are contractions of longer terms) for each of Read 4 byte, Version 2 and Version 3 (fields 1-8). It is the Version 2 Read code (V2_READ_CODE - field 3) and the Version 2 Term (V2_TERM - field 5) which are actually carried in EDI messages. Field 1(FOURBYTE_READ_CODE) carries a default code in all editions from October 2009 onwards. In order to minimise the effect on loading routines, the 4-byte column has been allocated a default value of 4. for the 4-byte code, and Laboratory procedures for the 4- byte term. No problems were identified from testing or reported subsequently but system suppliers and laboratories should still note the potential for this code mismatch to cause issues when codes are loaded. Metadata Flags Each record contains a number of flags for each concept (fields 11-18), relating to whether the laboratory investigation might be requested (REQUEST - field 12) and/or reported (REPORT - field 11), whether it might be used as a battery (BATTERY - field 13) and/or a test (TEST - field 15), and the type of result that might be produced (LEVEL - field 14, BOOLEAN - field 17, TEXT - field 18). Where a flag has a value of 'T' (True), it means that it is permissible (but not required) for the use of that Read code for that purpose, and that a flag of 'F' (False) means the opposite, i.e. the use of that Read code for that purpose is not expected (e.g. a Read code with a BATTERY flag of 'F' (False) should not be used for a battery). 6

10 At this stage, it is neither expected nor anticipated that any use be made of these flags by recipient systems. They are there for guidance for laboratory implementers, and their validity needs confirming through use. The one exception to this relates to the ratio flag (RATIO - field 16), which is used to indicate those investigations producing a numeric result for which the presence of an associated measurement unit is not mandatory. Note that not all of these investigations are ratios, that some ratios do not have this flag set to 'T' (True), and that recipient systems are not required to validate according to this flag, although they may do so. Status Field Each record also has a status of 'C' (Current) or 'D' (Deleted) (STATUS - field 19). Where a code is marked as deleted, a comment (COMMENTS - field 10) is included giving the reason for deletion and usually referring to alternative code(s) to use. Comments are also included for a small number of current records. It is neither expected nor anticipated that systems suppliers add any functionality to their systems to make use of the STATUS field at this stage, and in particular it is expected that GP systems suppliers shall not provide functionality to reject messages containing deleted codes. Other Fields Each record also contains the date of the version of the bounded list in which the Read code first appeared (RELEASE_DATE - field 20). A key (or abbreviation) commonly used for the concept may be given (KEY - field 9). Please note that these are not unique. Please note that all data in the Labset files in addition to the standard terms and codes are informative and for recommended use and guidance only. Items previously identified for deprecation in the April 2015 PBCL release will continue to be reviewed under current PBCL governance arrangements. More information about current primary care pathology informatics governance arrangements are available on request to diagnosticsdata@hscic.gov.uk. Health and Social Care Information Centre 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE 7