HL7 Medical Record/Information Management



Attendees:

Tuesday Afternoon: Wayne Tracy, Michelle Dougherty, Scott Robertson, Joann Larson, Barbara Jett, Maureen Donahoe, Harry Rhodes, Liora Alschuler

Wednesday Morning: Joint meeting between Medical Records and Structured Documents: Wayne Tracy, Michelle Dougherty, Bob Dolan, Calvin Beebe, Sandy Boyer, Maureen Donahoe, Mike Neimi, Jill Kaufman, Rhonda Delmater, Ammon Shubo, Matthew Green, Chris Voigt

Wednesday Afternoon: Wayne Tracy, Michelle Dougherty, Maureen Donahoe, Barbara Jett, Matthew Green, Harry Rhodes

Thursday Morning: Joint meeting between Medical Records and Structured Documents: Robert Dolan, Wayne Tracy, Michelle Dougherty, Harry Solomon, K.P. Lee, Sam Heard, Ed Larsen, Maureen Donahoe, Andrew Perry, Ammon Shabo, Robert Stegwer, Fred Behlen, Harry Rhodes, Fred Owens

Highlights:

• Reviewed first ballot comments for HL7 Version 2.5 Chapter 9 (Tuesday p.m. and Wednesday p.m.)

1. Larson, Joann (Kaiser Permanente)……………………………………………… 2

2. Oemig, Frank (HL7 Germany)……………………………………………………4

3. Alschuler, Liora (The Word Electric)……………………………………………. 5

4. Epic Systems (Marueen Donahoe) ………………………………………………. 7

5. Shanney, Anne (IDX Systems Corp)…………………………………………… 10

6. Meyer, Chuck (McKesson Information Solutions)………………………………11

7. Miller, Joan (Siemens Medical Solutions)……………………………………….14

8. Scholtz, Peter (HL7 Germany) ………………………………………………….16

• Reviewed version 3 second ballot comments for records (Wednesday a.m. and Thursday a.m.)

1 Lorenzi, Virginia (First Consulting Group) 1

2 Nelson, Dale (Oracle) 2

3 Schadow, Gunther (Regenstrief Institute for Health Care) 4

4 Walker, Mead (Mead Walker Consulting) 9

(Note: The version 3 comments are hyperlinked to the location in the minutes. The page number refers to the original document provided by Bob Dolan rather than the page in the MR/IM Minutes)

• MR/IM TC voted to use CDA exclusively for medical record document content.

Tuesday p.m.

Medical Records / Information Management

Ballot Reconciliation Package – V2.5 Messages

May 2002 Working Group Meeting

Ballot results are located in the Disposition Comment column for V2.5:

Larson, Joann (Kaiser Permanente)

|ID |Section|Chapter |Vote|Type|Existing |Proposed |Comments |Disposition |Disposition Comment |

|# | | | | |Wording |Wording | | | |

|9-1|9.5 |9 |  |T |  |  |Editorial correction. For all |Accept |Place a B in status column |

| | | | | | | |messages in section 9.5, the | |for an EVN eliminating the |

| | | | | | | |EVN segment needs to be marked | |highlighting in column 2 |

| | | | | | | |as "B" in the status column. | |pending approval by ARB; |

| | | | | | | | | |Ballot: 7 in favor 0 opposed|

| | | | | | | | | |0 abstained (7-0-0) |

|9-2|9.5.2 |9 |  |T |{OBX} [{ |{OBX [{ |The NTE for the OBX needs to be|Accept |There appears to be a |

| | | | | |NTE}] |NTE}] } |bound to the repetition of the | |missing terminal brace and |

| | | | | | | |OBX, otherwise there is no | |bracket at the end of the |

| | | | | | | |direct association. This change| |group which was found in |

| | | | | | | |needs to be applied to the T04,| |hidden text and will be |

| | | | | | | |T06, T08 and T10 as well. | |corrected. Corrected the |

| | | | | | | | | |repeating OBX by inserting |

| | | | | | | | | |on its own line a brace and |

| | | | | | | | | |ending brace (applying |

| | | | | | | | | |standard format for OBX |

| | | | | | | | | |group. Ballot: 7-0-0 |

|9-3|9.6.1.1|9 |  |S |  |  |Editorial correction for |Accept |Reference corrected. Ballot:|

| |2 | | | | | |TXA-12. Reference should be to | |7-0-0 |

| | | | | | | |2.16.94 - XTN, not 2.9.55. | | |

|9-4|9.8.1.1|9 |  |  |QRD-12-Quer|QRD-12-Que|Editorial correction, wrong |Accept |Reference corrected. Ballot:|

| | | | | |y Results |ry Results|reference; should be chapter 5,| |7-0-0 |

| | | | | |Level |Level |not 2. | | |

| | | | | |determines |determines| | | |

| | | | | |the amount |the amount| | | |

| | | | | |of data |of data | | | |

| | | | | |requested. |requested.| | | |

| | | | | |See Chapter|See | | | |

| | | | | |2, Section |Chapter 5,| | | |

| | | | | |5.10.5.3.12|Section | | | |

| | | | | |, “Query |5.10.5.3.1| | | |

| | | | | |Results |2, “Query | | | |

| | | | | |Level.” |Results | | | |

| | | | | | |Level.” | | | |

|9-5|9.9.4 |9 |  |Q |  |  |I do not see the new CON |Defer |Vote to defer. Joann Larson |

| | | | | | | |segment in the MDM messages. | |will represent MR/IM TC at |

| | | | | | | |Has it been applied to any | |the ARB to approve the CON |

| | | | | | | |other message? If not, it needs| |so it is definition without |

| | | | | | | |to be brought to the attention | |application. |

| | | | | | | |of the ARB. The ARB has | | |

| | | | | | | |articulated new policies and | | |

| | | | | | | |decides on a case-by-case basis| | |

| | | | | | | |if a new segment can be created| | |

| | | | | | | |without being a part of a | | |

| | | | | | | |message. There is no reason to | | |

| | | | | | | |think they would reject the | | |

| | | | | | | |CON; they just need to evaluate| | |

| | | | | | | |it. Or, we need to apply it | | |

| | | | | | | |somewhere. | | |

|9-6|9.9.4 |9 |  |Q |  |  |Has this new segment been |Defer |Noted and agree that work |

| | | | | | | |correlated with the | |needs to continue. |

| | | | | | | |pre-existing consent fields in | | |

| | | | | | | |the OM7 as defined in chapter | | |

| | | | | | | |8, section 8.8.14? If not , we | | |

| | | | | | | |run the risk of our master file| | |

| | | | | | | |segment being out of sync with | | |

| | | | | | | |the message segment it should | | |

| | | | | | | |be supporting. Also, the | | |

| | | | | | | |addition of this segment may | | |

| | | | | | | |call for modification of the | | |

| | | | | | | |OM7. | | |

|9-7|9.9.4.1|9 |  |S |Definition:|Definition|Standard language as used in |Accept |Accepted recommended |

| | | | | |Uniquely |: This |other chapters should be used | |definition. Definition: |

| | | | | |identifies |field |here. | |This field contains the |

| | | | | |a |contains | | |number that identifies this |

| | | | | |particular |the number| | |segment instance within the |

| | | | | |consent |that | | |message. For the first |

| | | | | |segment |identifies| | |occurrence of the segment, |

| | | | | |within a |this | | |the sequence number shall be|

| | | | | |message |transactio| | |one, for the second |

| | | | | | |n. For | | |occurrence, the sequence |

| | | | | | |the first | | |number shall be two, etc. |

| | | | | | |occurrence| | |Ballot: 7-0-0 |

| | | | | | |of the | | | |

| | | | | | |segment, | | | |

| | | | | | |the | | | |

| | | | | | |sequence | | | |

| | | | | | |number | | | |

| | | | | | |shall be | | | |

| | | | | | |one, for | | | |

| | | | | | |the second| | | |

| | | | | | |occurrence| | | |

| | | | | | |, the | | | |

| | | | | | |sequence | | | |

| | | | | | |number | | | |

| | | | | | |shall be | | | |

| | | | | | |two, etc. | | | |

|9-8|9.9.4.2|9 |  |Q |  |  |Isn't a data type of CNE |Defer |Believe that CNE means coded|

| | | | | | | |inconsistent with a | |no exception for a user |

| | | | | | | |user-defined table? See chapter| |defined table. Must have a |

| | | | | | | |2, sections 2.5.3.6, 2.16.11 | |step between a CNE and CDW. |

| | | | | | | |and 2.16.16. | |Deferred pending action by |

| | | | | | | | | |Joann Larson to clarify. |

| | | | | | | | | |Ballot: 7-0-0 |

|9-9|9.9.4.3|9 |  |Q |  |  |Is CON-3 the same concept as |Defer |Defer for future week. |

| | | | | | | |OM7-12? If so, they are not the| |Perhaps both OM7-12 and COM3|

| | | | | | | |same data type and should be | |should be changed to EI. |

| | | | | | | |coordinated. | |Ballot: 7-0-0 |

|9-1|9.9.4.4|9 |  |Q |  |  |I presume this is a specific |  |No action needed. |

|0 | | | | | | |instance of a consent as | |Presumption is correct. |

| | | | | | | |applied to a patient and thus | | |

| | | | | | | |would not have a counter-part | | |

| | | | | | | |in the OM7. | | |

|9-1|9.9.4.5|9 |  |  |Repetitions|  |Suggest that this sentence be |Accept |Accepted recommendation to |

|1 | | | | |may be used| |struck and that the max length | |strike statement and add max|

| | | | | |if the | |for FT of 64 K be applied to | |length for 9-11through 9-15.|

| | | | | |length of | |the field. | |Ballot: 7-0-0 |

| | | | | |the first | | | | |

| | | | | |repetition | | | | |

| | | | | |is | | | | |

| | | | | |insufficien| | | | |

| | | | | |t. | | | | |

|9-1|9.9.4.6|9 |  |  |Repetitions|  |Suggest that this sentence be |Accept |Accepted recommendation to |

|2 | | | | |may be used| |struck and that the max length | |strike statement and add max|

| | | | | |if the | |for FT of 64 K be applied to | |length for 9-11through 9-15.|

| | | | | |length of | |the field. | |Ballot: 7-0-0 |

| | | | | |the first | | | | |

| | | | | |repetition | | | | |

| | | | | |is | | | | |

| | | | | |insufficien| | | | |

| | | | | |t. | | | | |

|9-1|9.9.4.7|9 |  |  |Repetitions|  |Suggest that this sentence be |Accept |Accepted recommendation to |

|3 | | | | |may be used| |struck and that the max length | |strike statement and add max|

| | | | | |if the | |for FT of 64 K be applied to | |length for 9-11through 9-15.|

| | | | | |length of | |the field. | |Ballot: 7-0-0 |

| | | | | |the first | | | | |

| | | | | |repetition | | | | |

| | | | | |is | | | | |

| | | | | |insufficien| | | | |

| | | | | |t. | | | | |

|9-1|9.9.4.8|9 |  |  |Repetitions|  |Suggest that this sentence be |Accept |Accepted recommendation to |

|4 | | | | |may be used| |struck and that the max length | |strike statement and add max|

| | | | | |if the | |for FT of 64 K be applied to | |length for 9-11through 9-15.|

| | | | | |length of | |the field. | |Ballot: 7-0-0 |

| | | | | |the first | | | | |

| | | | | |repetition | | | | |

| | | | | |is | | | | |

| | | | | |insufficien| | | | |

| | | | | |t. | | | | |

|9-1|9.9.4.9|9 |  |  |Repetitions|  |Suggest that this sentence be |Accept |Accepted recommendation to |

|5 | | | | |may be used| |struck and that the max length | |strike statement and add max|

| | | | | |if the | |for FT of 64 K be applied to | |length for 9-11through 9-15.|

| | | | | |length of | |the field. | |Ballot: 7-0-0 |

| | | | | |the first | | | | |

| | | | | |repetition | | | | |

| | | | | |is | | | | |

| | | | | |insufficien| | | | |

| | | | | |t. | | | | |

|916|9.9.4.1|9 |N |Mi |  |  |Data type of CON-18 is listed |Accept |Accept recommendation to use|

| |8 | | | | | |as ID; this is inconsistent | |the HL7 language table. |

| | | | | | | |with the association of a | |Changed table ISO 639 to |

| | | | | | | |user-defined table. Also, | |0296. Ballot: 7-0-0 |

| | | | | | | |there is already a table number| | |

| | | | | | | |for language "0296" - as used | | |

| | | | | | | |in the PID- 15. We probably | | |

| | | | | | | |should not define a second one.| | |

| | | | | | | |The MSH - 19 also refers to ISO| | |

| | | | | | | |639, but does not refer to a | | |

| | | | | | | |HL7 table number. All of these | | |

| | | | | | | |should be consistent. | | |

|9-1|9.9.4.1|9 |  |S |  |  |Based on the definition, it |Accept |Accepted recommendation to |

|7 |8 | | | | | |looks like the field would be | |allow editor to use their |

| | | | | | | |better named Translated | |discretion "Translated |

| | | | | | | |Language or something. | |Language (to)" to describe |

| | | | | | | | | |the language which was used |

| | | | | | | | | |to communicate the consent. |

| | | | | | | | | |Ballot: 7-0-0 |

|9-1|9.9.4.2|9 |  |Q |  |  |Isn't a data type of CNE |Defer |Believe that CNE means coded|

|8 |2 | | | | | |inconsistent with a | |no exception for a user |

| | | | | | | |user-defined table? See chapter| |defined table. Must have a |

| | | | | | | |2, sections 2.5.3.6, 2.16.11 | |step between a CNE and CDW. |

| | | | | | | |and 2.16.16. | |Deferred pending action by |

| | | | | | | | | |Joann Larson to clarify. |

| | | | | | | | | |Ballot: 7-0-0 |

Oemig, Frank (HL7 Germany)

|ID|Section |Chapter |Vote |Type |Existing Wording |Proposed |Comments |Dispositi|Disposition Comment |

|# | | | | | |Wording | |on | |

|  |9.2 |9 |N |Mj |Document/reports |Chapter 7, |Criteria not |Defer |Approved the proposal |

| | | | | |supported in this |section 7.2 |definitive with | |to have Scott Robertson|

| | | | | |chapter will meet the |If the |respoect to CDA.| |craft a paragraph for |

| | | | | |criteria as described in|observation |If intended to | |Chapter 7 for moving |

| | | | | |Chapter 7 (section 7.2 –|being reported |restrict | |the signature down. |

| | | | | |Purpose). |meets one or |transmission of | |Liora agrees to remove |

| | | | | | |more of the |CDA to MDM, then| |negative if bullet on |

| | | | | |Chapter 7, section 7.2: |following |contradicts | |signature is moved down|

| | | | | |If the observation being|criteria, then |ANSI/HL7 CDA | |and if 7 agrees to put |

| | | | | |reported meets one or |the content |1.0, section | |the change in their |

| | | | | |more of the following |would qualify |2.5.2 which | |chapter. Ballot: 6-0-0 |

| | | | | |criteria, then the |as a medical |states: | | |

| | | | | |content would qualify as|document |"CDA documents | | |

| | | | | |a medical document |management |are to be | | |

| | | | | |management message (MDM)|message (MDM) |exchanged in the| | |

| | | | | |rather than an |rather than an |OBX segment, in | | |

| | | | | |observation message |observation |any message that| | |

| | | | | |(ORU) and the payload |message (ORU). |can exchange | | |

| | | | | |may be a CDA document. |CDA documents |documents (such | | |

| | | | | | |are to be |as MDM and ORU).| | |

| | | | | | |exchanged in |" | | |

| | | | | | |the OBX |(NOTE: same | | |

| | | | | | |segment, in any|vote/comment | | |

| | | | | | |message that |submitted for | | |

| | | | | | |can exchange |Ch.7) | | |

| | | | | | |documents | | | |

| | | | | | |including the | | | |

| | | | | | |MDM and ORU. | | | |

|  |9.3 |9 |N |Mi | The document management|add: Documents |not sure where, |Accept |Agreed to add to 9.3 |

| | | | | |section is concerned |may be CDA |but CDA should | |paragraph 2: Document5 |

| | | | | |primarily with the |documents. See|be defined and | |may be represented as a|

| | | | | |management of those |ANSI/HL7 CDA |referenced | |CDA document. See |

| | | | | |documents and entries |R1.0-2000 |somewhere so the| |ANSI/HL7 CDA R1.0-2000 |

| | | | | |which are created as a |Section 2.5.2 |acronym can be | |Section 2.5.2 for the |

| | | | | |result of a |for the correct|used. | |correct method of |

| | | | | |transcription process. |method of | | |transmitting CDA |

| | | | | | |transmitting | | |documents within an MDM|

| | | | | | |CDA documents | | |message. Ballot: 6-0-0 |

| | | | | | |within an MDM | | | |

| | | | | | |message. | | | |

|  |9.5 |9 |A |Q |Medical |  |Strikes me as |  |  |

| | | | | |Records/Information | |very difficult | | |

| | | | | |Management (Document | |to verify, | | |

| | | | | |Management) messaging | |especially wrt | | |

| | | | | |does not support the | |CDA. | | |

| | | | | |concept of partial or | | | | |

| | | | | |preliminary results. | | | | |

|  |9.6.1.3 |9 |N |Mi |Definition: This is a |Add: CDA |per CDA 2.5.2 |Accept |Agreed to add CDA per |

| | | | | |conditional field which |documents are | | |2.5.2 in comment field |

| | | | | |is required whenever the|sent with the | | |of multipart. Ballot: |

| | | | | |message contains content|value = | | |6-0-0 |

| | | | | |as pre-sented in one or |multipart | | | |

| | | | | |more OBX segments. This|Add: to table | | | |

| | | | | |field identifies the |row 5, col 2: | | | |

| | | | | |method by which this |MIME multipart | | | |

| | | | | |document was ob-tained |package (CDA) | | | |

| | | | | |or originated. | | | | |

|  |9.6.2 |9 |A |S |  |Either add OBX |  |Defer |Defer to chapter 7 for |

| | | | | | |values for CDA | | |resolution. |

| | | | | | |to Ch. 7 or | | | |

| | | | | | |state here: | | | |

| | | | | | |"OBX values for| | | |

| | | | | | |CDA are | | | |

| | | | | | |documented in | | | |

| | | | | | |CDA 2.5.2" | | | |

|  |9.7 |9 |A |S |Sample message |Add sample |  |  |Liora agreed to provide|

| | | | | | |message with | | |a sample message and TC|

| | | | | | |encapsulated | | |agreed to include as an|

| | | | | | |CDA from CDA | | |example in the chapter.|

| | | | | | |2.5.2 | | | |

Epic Systems (presented by Maureen Donahoe)

Ballot comments for Epic were not provided to MR/IM. Committee agreed to review and address comments.

|ID|Section |Chapter |Vote |Type |Existing Wording |Proposed |Comments |Disposi|Disposition Comment |

|# | | | | | |Wording | |tion | |

|  |9.5.1 |9 |N |Mi |[{ |[{ |No good reason | Cancel| There is content in |

| | | | | |ORC |OBR |given for the | |ORC that is not |

| | | | | |OBR |[{ NTE }] |existence of the | |available anywhere |

| | | | | |[{ NTE }] |}] |ORC segment. No | |else. When a report is |

| | | | | |}] | |loss of | |provided based on an |

| | | | | | | |functionality or | |order, the intent to |

| | | | | | | |data if ORC is not| |use an ORC was to keep |

| | | | | | | |part of the | |from writing 2 |

| | | | | | | |message. | |messages. |

| | | | | | | | | |Committee does agree |

| | | | | | | |The same coment | |with the comment and |

| | | | | | | |for sections: | |finds it |

| | | | | | | |9.5.2 (T02 event) | |non-persuasive . |

| | | | | | | |9.5.3 (T03 event) | |Ballot: 4-1-0 |

| | | | | | | |9.5.4 (T04 event) | | |

| | | | | | | |9.5.5 (T05 event) | | |

| | | | | | | |9.5.6 (T06 event) | | |

| | | | | | | |9.5.7 (T07 event) | | |

| | | | | | | |9.5.8 (T08 event) | | |

| | | | | | | |9.5.9 (T09 event) | | |

| | | | | | | |9.5.10 (T10 event)| | |

| | | | | | | |9.5.11 (T11 event)| | |

|  |9.5 |9 |N |Mi |Also, the orders |The orders |Not certain what | Cancel|Discussed the rationale|

| | | | | |represented by the |represented by |the purpose of the| |for the wording. The |

| | | | | |ORC/OBR segments must be|the ORC/OBR |"wholly" | |TC |

| | | | | |wholly and exclusively |segments must |restriction is. | |didn’t agree with the |

| | | | | |satisfied by the TXA/OBX|be exclusively | | |comment and found it |

| | | | | |content. “Wholly |satisfied by | | |non-persuasive. |

| | | | | |satisfied” means there |the TXA/OBX | | |Ballot: 4-1-0 |

| | | | | |are no other orders |content. | | | |

| | | | | |related to the TXA/OBX |“Exclusively | | | |

| | | | | |content other than those|satisfied” | | | |

| | | | | |specified by the ORC/OBR|means that the | | | |

| | | | | |segments. “Exclusively |actions | | | |

| | | | | |satisfied” means that |described by | | | |

| | | | | |the actions described by|the ORC/OBR | | | |

| | | | | |the ORC/OBR segments do |segments do not| | | |

| | | | | |not contain actions not |contain actions| | | |

| | | | | |addressed by the TXA/OBX|not addressed | | | |

| | | | | |content. |by the TXA/OBX | | | |

| | | | | | |content. | | | |

|  |9.5.2 |9 |N |Mj |MDM^T02^MDM_T02 |MDM^T02^MDM_T02|Two things: |  |Withdrawn – this issue |

| | | | | |MSH |MSH |* Proper closing | |was addressed and |

| | | | | |EVN |EVN |of the brackets | |resolved in comments |

| | | | | |PID |PID |around the ORC, | |submitted by Joann |

| | | | | |PV1 |PV1 |OBR, NTE group | |Larson of Kaiser |

| | | | | |[{ |[{ |* NTE's associated| |Permanente. |

| | | | | |ORC |ORC |with OBX's; the | | |

| | | | | |OBR |OBR |NTE's, if present,| | |

| | | | | |[{ NTE }] |[{ NTE }] |should be | | |

| | | | | | |}] |associated with a | | |

| | | | | |TXA |TXA |particular OBX, | | |

| | | | | |{OBX} |{OBX |not appearing at | | |

| | | | | |[{ NTE }] |[{ NTE }] |the end of the | | |

| | | | | | |} |meessage in their | | |

| | | | | | | |own. | | |

| | | | | | | | | | |

| | | | | | | |Same issue in the | | |

| | | | | | | |following | | |

| | | | | | | |charters: | | |

| | | | | | | |9.5.4 (T04 event) | | |

| | | | | | | |9.5.6 (T06 event) | | |

| | | | | | | |9.5.8 (T08 event) | | |

| | | | | | | |9.5.10 (T10 event)| | |

|  |9.5 |9 |N |Mi |When optional order |When optional |Addition of two | Accept| TC agreed with |

| | | | | |components are included |order |extra bullets for | |comments and will add |

| | | | | |in the message overlap |components are |the placer and | |two more bullets to 9.5|

| | | | | |of field content between|included in the|order numbers | |above current bullets. |

| | | | | |TXA and the content in |message overlap|between the OBR | |The placer order number|

| | | | | |two OBR fields can |of field |and TXA segments. | |may exist in the ORC, |

| | | | | |exist. |content between| | |OBR and TXA. If valued|

| | | | | | |TXA and the |The second bullet | |in the ORC or OBR and |

| | | | | | |content in two |is there for | |the TXA is present, it |

| | | | | | |OBR fields can |backward | |should not be valued. |

| | | | | | |exist. |compatibility. | |If TXA is valued it |

| | | | | | | |TXA-14 is a | |should be ignored. |

| | | | | | |* The OBR-2 |repeating field, | |The filler order number|

| | | | | | |Placer Order |while TXA-15 is | |may exist in the ORC, |

| | | | | | |Number and |not. The second | |OBR and TXA. If valued|

| | | | | | |TXA-14 Placer |bullet tries to | |in the ORC or OBR and |

| | | | | | |Order Number |emulate the | |the TXA is present, it |

| | | | | | |are |previous situation| |should not be valued. |

| | | | | | |conseptually |were more than one| |If TXA is valued it |

| | | | | | |the same. If |placer order | |should be ignored. |

| | | | | | |both fields are|numbers were | | |

| | | | | | |valued, the |present in TXA-14 | | |

| | | | | | |contents of the|and only one | | |

| | | | | | |message are |filler order | | |

| | | | | | |assumed to |number was placed | | |

| | | | | | |target the |in TXA-15. | | |

| | | | | | |union of the | | | |

| | | | | | |order numbers | | | |

| | | | | | |present in | | | |

| | | | | | |OBR-2's and | | | |

| | | | | | |TXA-14. | | | |

| | | | | | | | | | |

| | | | | | |* The OBR-3 | | | |

| | | | | | |Filler Order | | | |

| | | | | | |Number and | | | |

| | | | | | |TXA-15 Filler | | | |

| | | | | | |Order Number | | | |

| | | | | | |are | | | |

| | | | | | |conseptually | | | |

| | | | | | |the same. If | | | |

| | | | | | |multiple OBR | | | |

| | | | | | |segments are | | | |

| | | | | | |present they | | | |

| | | | | | |should all have| | | |

| | | | | | |the same values| | | |

| | | | | | |for OBR-3. If | | | |

| | | | | | |a value is | | | |

| | | | | | |inlcuded in | | | |

| | | | | | |TXA-15, it | | | |

| | | | | | |should be the | | | |

| | | | | | |same as the | | | |

| | | | | | |common value in| | | |

| | | | | | |the OBR-3's, | | | |

| | | | | | |otherwise it is| | | |

| | | | | | |ignored. | | | |

Wednesday a.m. (Joint Meeting with Structured Documents):

Review V3 second ballot comments related to records. See minutes for Thursday a.m. for all comments and ballot reconciliation completed Wednesday a.m. and Thursday a.m.

Wednesday p.m.

Medical Records / Information Management

Ballot Reconciliation Package – V2.5 Messages Continued

May 2002 Working Group Meeting

Shanney, Anne (IDX Systems Corporation)

|ID # |Section |Chapter |Vote |Type |Existi|Proposed |Comments |Disposition |Disposition | |

| | | | | |ng |Wording | | |Comment | |

| | | | | |Wordin| | | | | |

| | | | | |g | | | | | |

|96 |TE |4, 8 |RCMR |N |Mi |Document |Separate trigger |Less ambiguity,|Reject |The "Original Document |

| | | | | | |Status |events should be |opportunity for| |Notification (and Content)"|

| | | | | | |Change |defined for each |more | |trigger is associated with |

| | | | | | | |document state |constraints and| |the following two state |

| | | | | | | |transition. As a |less | |transitions: |

| | | | | | | |result information |optionality. | |Act.null.activate |

| | | | | | | |for each can be | | |Act.null.create |

| | | | | | | |constrained based on| | | |

| | | | | | | |the need for that | | |In addition, there are |

| | | | | | | |transition. | | |several cases where two |

| | | | | | | | | | |triggers (with and without |

| | | | | | | | | | |content) result in the same|

| | | | | | | | | | |state change. |

| | | | | | | | | | | |

| | | | | | | | | | |We've discussed this M&M |

| | | | | | | | | | |and believe this is |

| | | | | | | | | | |acceptable per their |

| | | | | | | | | | |guidelines. It's important |

| | | | | | | | | | |that we use the V2 triggers|

| | | | | | | | | | |in the initial ballot of V3|

| | | | | | | | | | |to help adopt the new |

| | | | | | | | | | |standard. We will continue |

| | | | | | | | | | |to abide by M&M guidelines.|

| | | | | | | | | | |For now, we prefer to leave|

| | | | | | | | | | |as is. |

| | | | | | | | | | | |

| | | | | | | | | | |Favor: 10 |

| | | | | | | | | | |Opposed: 0 |

| | | | | | | | | | |Abstain: 0 |

Nelson, Dale (Oracle)

|ID # |Artifac|Section|Domain |Vote|Type |Existing|Proposed |Comments |Dispositio|Disposition Comment |

| |t | | | | |Wording |Wording | |n | |

|8 |?? |Records|RCMR |A |Q |  |  |– Should narrative document |Accept |The Clinical Document class is |

| | | | | | | | |content be stored in | |not derived from the |

| | | | | | | | |observation.value rather than | |Observation class, and does not|

| | | | | | | | |act.txt. (See RMIM RCMR_RM000002, | |have a Value attribute. We |

| | | | | | | | |A_Narrative_document_content). If | |discussed this at length with |

| | | | | | | | |we leave it in Act.txt we need to | |Gunther who feels strongly that|

| | | | | | | | |make the definition of act.txt | |we should be using Act.txt. |

| | | | | | | | |clearer, since act.txt seems to | |(Gunther and Fred Behlen have |

| | | | | | | | |allow only an annotation of the | |agreed to craft the revised |

| | | | | | | | |act, as opposed to its main | |text in time for the next RIM |

| | | | | | | | |clinical content. | |Harmonization meeting.) |

| | | | | | | | | | |(10-0-2) |

|9 |?? |Records|RCMR |A |Q |  |  |. The RMIM hierarchy between |Accept |Yes, the tooling supports this.|

| | | | | | | | |A_Document_section and the choice | | |

| | | | | | | | |box that also contains | | |

| | | | | | | | |A_Document_section is clearly | | |

| | | | | | | | |recursive. It appears that you go | | |

| | | | | | | | |from the document header to a | | |

| | | | | | | | |document section to a choice box, | | |

| | | | | | | | |which itself contains a document | | |

| | | | | | | | |section. Does the XML ITS support | | |

| | | | | | | | |this kind of extended recursion? | | |

| | | | | | | | |Same question for Rose_tree. | | |

|10 |?? |Records|RCMR |A |S |  |  |In the documentation, the status |Reject |Documents can only be of |

| | | | | | | | |code of completed is missing. | |ActStatus "new", "active", |

| | | | | | | | | | |"cancelled", and "obsolete". |

| | | | | | | | | | |They can't be "completed". A |

| | | | | | | | | | |document, once released for |

| | | | | | | | | | |patient care, has become |

| | | | | | | | | | |"active". From there it can be |

| | | | | | | | | | |over-ridden by a revision, in |

| | | | | | | | | | |which case it's status becomes |

| | | | | | | | | | |"obsolete". A document that was|

| | | | | | | | | | |"new" and never released for |

| | | | | | | | | | |patient care can be rendered |

| | | | | | | | | | |"cancelled". We'll add this |

| | | | | | | | | | |clarification to the ballot. |

| | | | | | | | | | |(9-0-0) |

|11 |?? |Records|RCMR |N |Mi |  |  |In the RMIM "cancel" status is |Reject |"Cancel" is an Act state, and |

| | | | | | | | |included. However in the “Record” | |is part of the ActState domain.|

| | | | | | | | |vocabulary section cancel is not | |The state of a document is |

| | | | | | | | |a document completion status. | |orthogonal to the document |

| | | | | | | | | | |completion status, and |

| | | | | | | | | | |therefore there is no need to |

| | | | | | | | | | |have "Cancel" in the |

| | | | | | | | | | |DocumentCompletion vocabulary |

| | | | | | | | | | |domain. (9-0-0) |

Schadow, Gunther (Regenstrief Institute for Health Care)

“O.K. we are asked to vote this as one chapter. Clearly there is a break between the Lab and Pharmacy sections and the "Records" section. I have most comments on the Records

sections because I'm so intimately involved in the other two.”

Records

NEGAT: the introduction rightfully says it's about document management and transcription. The section title "Records" is therefore too broad. All of the orders and results messages are "records" just as well. We are sending the wrong signal saying that healthcare operation and records are two distinct areas.

Reject

The committee has always been named “Medical Records / Information Management”. While our current messages are about documents, the scope of our TC is the Medical Record. Our current range of messages is admittedly limited to documents and document management, but the scope of our TC is broader, and you don’t want to be revising the TOC of the ballot when in the future we produce more messages. The label used in the Table of Contents should be reflective of the mission/charter/scope of the TC, rather than our current suite of messages.

Favor: 7

Opposed: 0

Abstain: 3

--

RMIM and vocabulary

---

NEGAT: Some Act_relationship type codes need cleanup.

XFRM defined twice should follow revision semantics, i.e., the source is a transformation of the target.

Accept

Will only leave it under DocumentRelationship, and re-check the correct definition.

SUCC isn't defined as to source / target. Make it source succeeds target.

We don’t use this one. Gunther withdraws this comment from our ballot.

RPLC isn't defined as to source / target. Mark is source replaces target. just like APND.

move those documentRelationships under the RVSN category.

Accept

We’ll make the following change:

Before:

DocumentRelationship

APND

RPLC

XFRM

RPLC

SUCC

RVSN

APND

XFRM

After:

RVSN ( (Name that Gunther will propose)

APND

RPLC

SUCC

XFRM

Favor: 10

Opposed: 0

Abstain: 2

---

NEGAT: AR_Documentation_of_order, A_Order_fulfillment, AR_Fulfills_order A_Order, and AR_Fulfills

- why is the generic act event called "order fulfillment"? Is the documented service (clinical act) always in response to an order? I guess not (all of surgery is basically not ordered, notes, discharge summaries, etc.)

- AR_Fulfills / FLFS is problematic. If you split the documentation from the performed service (which I think is a problem in itself) and the service fulfills the order, then the document doesn't also fulfill the order. This relates to the general problem I have with the document act-relationships. It would fit better if they were all considered under the revision categroy: a document is then simply one rendition of the service/procedure information and as such one could accept that it fulfills the order just as much as the procedure act object fulfills the order.

Accept.

See revised Visio. Change to just having AR_Documentation_of_act and A_Documented_act.

Favor: 9

Opposed: 0

Abstain: 2

---

NEGAT: AR_Related_encounter now says that the encounter IS a component of the document. That's not right.

Accept

See modified Visio.

Favor: 7

Opposed: 0

Abstain: 4

---

NEGAT: I don't agree with the way the document content is modeled. This should be the stuff inside the A_Clinical_document.txt. Why don't we say that the document.txt simply encapsulates the document content. That could be anything, plain text, word, PDF, a scanned image, a custom HTML or XML instance or a CDA XML instance with or without multimedia pieces.

Why do you break out sections but not subsections?

I think that the transcription related domain should not attempt to model the structure of the information inside the document. That's the domain of the clinical information committees, such as orders observations, lab, pharmacy, patient care, and of course the CDA. In the present chapter that content structure should be encapsulated. We've got enough worries in harmonizing CDA with the structured clinical information areas, don't need a third approach to that.

Accept

See modified Visio. The payload (the document) is carried in Act.txt.

Favor: 9

Opposed: 0

Abstain: 2

---

NEGAT

In general, the R-MIM needs more description to provide guidance as to what information goes where and how these things are used. E.g. could imagine that the 4 participations to the Assigned practitioner CMET will be used inconsistently by implementers.

Why isn't the intended recipient also an "assigned practitioner"? The structure of the classes around R_HealthcareEntity looks very much like what's in the assigned practitioner CMET.

Withdrawn

---

AQUERY

P_Patient and P_Participant, unclear what function the P_Participant has.

Answered in session with Gunther.

---

NEGAT

P_Transcriptionist: why is this modeled specifically? It could just as well be an assigned entity CMET.

Agree

Will use the R_Assigned_practitioner_identified CMET.

Favor: 10

Opposed: 0

Abstain: 2

---

NEGAT

P_Originating_device: This one bothers me. It was this committee and CDA who made such a big point that we should not make a distinction between people and devices in the RIM and that had a HUGE impact in the LHS (Stakeholder vs. Material was merged into Entity.) Now you break device out again as separate????

Conclusion: to the preceding points: I think the assigned entity CMET can be used for all of the active partipants, incl. transcriptionists. The devices would then be covered automatically.

Agree

Merge the orginator person and device into a single participation “P_Originator” that points to a choice of CMETs “R_Assigned_practitioner_identified” or “R_Device_identified”. Change the lower cardinality of “_Originator from “0” to “1”.

Favor: 10

Opposed: 0

Abstain: 0

Walker, Mead (Mead Walker Consulting)

ID # |Artifact |Section |Domain |Vote |Type |Existing Wording |Proposed Wording |Comments |Disposition |Disposition Comment | |CL010 |?? |1.1 |MR |A |S | | |In the Introduction to the Medical Records domain section, it would be helpful to have a description of what is included as well as the overall scope of the domain. |Defer |Can Mr. Walker supply more specifics as to what he would like to see? As it stands, we feel that the current introduction correctly describes what is now in the ballot, and what we might likely anticpate adding in the future. (Mead - did you look at the Introduction under Records as well as the Introduction under Medical Records?) (9-0-1) | |CL011 |ST |2 |MR |A |S | | |In the storyboards for the section, it would be helpful, when attributes are named, to give their fully qualified name – with class name included. I am not sure if this is helpful for the storyboards. Certainly it is different from other sections. The committee should review the comments it receives and determine what to do. |Accept |We'll use the specialized class name and follow M&M naming conventions. (9-0-1) | |CL012 |RM |6 |MR |N |Mj | | |As with the LAB models, in the medical records RMIM, there appears to be overlaps between the Substance Order Intent participations and act relations and the Controlled Event Wrapper. The proper course for message implementers needs to be explained. (Note typo in section 6.1 “Heirarchical”) |Reject |We believe the participants in the wrapper are not the same as the participants in our R-MIM. Participants in the wrapper define who authored the message, who the message is intended for, message responsibilites, etc. (7-0-3) (But we will fix the typo) | |CL013 |RM |6 |MR |A |Q | | |In the RMIM, what is the role of P_intended_recipient? This seems to relate more to the messaging of a document than to the document itself. |Accept |This is used to indicate those people who should receive a copy of the document. (Mead - where is the correct place to offer additional clarifying narrative within the ballot itself? We will be happy to add this clarification there.) (8-0-1) | |

Agenda for Baltimore Meeting September 2002:

Tuesday a.m. – Ballot reconciliation 2.5 second ballot

Tuesday p.m. -- Ballot reconciliation 2.5 second ballot

Wednesday a.m. – Joint with structured documents

Wednesday p.m. – New HIPAA issues related to privacy and possible updates chapter 9

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