Transmitting Page Images in HL7 Attachments



HL7 White Paper:

Transmitting Images of Documents in HL7 Attachments

Wes Rishel

(Draft 11 20 May 2001)

Introduction 1

Definitions 1

Functional Approach 2

Requirements 2

Usage Scenarios 3

Scenario: CDO With No On-line Clinical Data 3

Scenario: CDO with Some On-line, Structured Clinical Data 4

Scenario: CDO with On-line Document Images 5

Scenario: CDO with On-line Document Images and On-line Structured Data 6

Scenario: Health Plan, Minimal Compliance 6

Scenario: Health Plan with Document Image Management System 6

Scenario: Health Plan with Aggressive Process Improvement 7

Technical Approach 7

Description 7

Specifications 12

Design Considerations 13

Choice of Image Format 13

Sending Raw Images in BIN Segments 14

Appendix 1: Alternative Image Formats 15

Appendix 2: Complete Example HL7 Message 18

Introduction

The May 2001 release of the HL7 LOINC Code Booklets {correct title?} for Claims Attachments include the changes that permit fax-like images of documents to be transmitted as claims attachments under certain specific circumstances. This paper gives the rationale for this addition, the functional approach, the business processes in care delivery organizations and health plans, the technical approach, and the rationale for the technical approach.

This document is written with the assumption that the reader is familiar with the X12N and HL7 implementation guides for claims attachments.[1],[2] Information on these and other X12/HIPAA-related implementation guides is available from the Washington Publishing Company, Gaithersburg, MD. .

Definitions

Attachment module — a collection of software functions that enables a user to interpret requests for claims attachments in an X12N 277 transaction and create claims attachments in X12N 275 transactions. This module might be part of a billing system, a medical records system, or a specialized product.

Care Delivery Organization (CDO) — an organization that qualifies as a healthcare provider under HIPAA.

LOINC® — Logical Observation Identifiers, Names, and Codes[3]

Structured data — data sent as discrete observations in a format that makes the information useful for processing by a computer. For claims attachments each element of structured data is available as a LOINC code.

Text data — is natural language information sent as a block of text that can be comprehended by a person but is not amenable to being used in computer-based decision algorithms. For claims attachments this data is sent as a single datum identified by a LOINC code.

User — a person who uses software to accomplish a task.

Functional Approach

The capability to send images is being added to achieve these benefits:

1. make attachments available sooner in CDOs that do not have Computer-based Patient Records or other sources of structured clinical data, and yet

2. retain the structure and specificity associated with the use of the ORU message and LOINC codes.

The specific approach is to permit a CDO to transmit fax-like images of document pages in most situations where they might otherwise send textual documents as an unstructured block of text. This approach retains the use of LOINC codes and HL7 messages to identify the data being transmitted. The only difference is that the data that accompanies the LOINC code in the HL7 OBX segment is an image rather than being a block of text.

The image may be a fragment of a page or a number of pages. Nonetheless, the entire image must contain data that is described by the associated LOINC code. If a single page contains clinical data other than that which is specified by the LOINC code, the CDO must clearly indicate which data on the page is responsive to the LOINC code. This provision is to relieve the payer from the requirement to examine a large volume of medical record data and make the judgement about which parts are applicable. It is also supportive of the HIPAA privacy regulation that requires minimum disclosure.

Under HIPAA, all health plans must prepare to meet all capabilities specified for claims attachments. The approach described here is limited to monochrome images of document pages that are of the same quality as is produced by facsimile machines on the "fine" or high-resolution setting. This limitation is a compromise between covering all possible claims attachments and placing processing burdens on the systems of health plans.

Some of the details of the approach described here are specific to the six claims attachments that are expected to be part of the initial Notice of Proposed Rulemaking (NPRM): ambulance, rehabilitation services, emergency department, clinical reports, laboratory data, and medications. For other attachments the approach may be expanded to provide better quality images or colors, but only after an examination of the benefits versus the impact on CDO and health plan systems and approval through the HL7 consensus process.

As with any part of the claims attachments specifications, the approach to imaging is subject to change after comments have been received to the NPRM.

Requirements

Purpose. This addition to the claims attachments specifications must permit CDOs to transmit images pages of paper documents for review by health plans as an aid to claims adjudication.

Contents. The images transmitted under this specific approach will represent documents that can contain a combination of printed and handwritten information, sketches, EKG traces and other information that might appear in a paper chart. Information can only be sent this way if transmission at the quality level of a fax document is suitable for determining benefits.

Image Source. The images may be scanned images of paper documents, but they may also be images that could have been printed on paper but, in fact, were created electronically using a technology such as Computer Output to Laser Disk (COLD).

Low Equipment Cost for CDOs. It must be possible to create the images for this specification using low-cost software and a scanner costing less than $150. At the same time it should be straightforward to integrate the images into the image document management systems of health plans that have these systems.

No Requirement for Health Plan to Purchase a Document Image Management System. It must be possible for health plans that do not choose to use a document image management system to process claims attachments containing images by printing the attachments on paper.

No Bilateral Specifications. The HL7 specifications must be complete. No supplementary bilateral specifications between trading partners should be necessary for interoperation.

Future Considerations. The general approach used here should permit adaptation to support other claims attachments and attachments specified for other purposes than providing information to support a healthcare claim. An analysis of the requirements of those applications may lead to differences in the types and parameters of image formats that will be specified.

Usage Scenarios See Scenarios.ppt

CDOs and health plans vary widely in the extent to which structured clinical data is available on-line. This section describes how the attachments approach, including the ability to send images, may be used in different organizations. The following scenarios are described.

• CDO with no on-line clinical data

• CDO with some on-line, structured clinical data

• CDO with on-line document images

• CDO with on-line document images and on-line structured data

• health plan with minimal compliance

• health plan with document image management system

• health plan with aggressive process improvement.

Within each scenario, several situations are described. Depending on the specific systems in a CDO and a specific request for attachments, one or more of the situations may apply.

Scenario: CDO With No On-line Clinical Data

Situation: Attachment is a chart document. A CDO determines the need to create a claims attachment, either to accompany a claim or in response to a request. The attachment module determines that the information is of the category for which document images are permitted and a user determines that it has a paper document that satisfies the question stated in the LOINC code.

The user selects the element of the request for which will be answered with an image, places the document on a scanner and the attachment module scans the document and includes its image and LOINC code in the appropriate places in the 275 transaction. If the document contains more information than is requested by the LOINC code, the attachment module permits the user to indicate which part of the document contains the information that is responsive to the request.

At the completion of collecting all attachments the attachment module sends the 275 to the health plan.

Situation: Document is Prepared Specifically for the Attachment. There may be circumstances where the information to be attached is specifically prepared for the attachment. The process is otherwise the same. The user creates the paper document and handles it as above.

Situation: Structured Data Required. Where the claims attachment specifications do not permit at least one of the requisite pieces of information to be sent as a document image, the attachment module might offer the user two choices:

1. key the data into the attachment module so it can be sent as structured data, or

2. send the entire set of attachments as paper.

Scenario: CDO with Some On-line, Structured Clinical Data

Situation: All Required Data That Must Be Structured Available On-line. The user determines which data can be retrieved from an on-line system of the CDO and the attachment module retrieves and inserts this information and the associated LOINC codes in the appropriate places in the 275 transaction.

For the remaining requisite information the attachment module determines that the information is of the category for which document images are permitted. The user finds or prepares paper, which the attachment module scans. The software inserts the images and the associated LOINC codes in the appropriate places in the 277 transaction. If a document that will be scanned contains more information than is requested by the LOINC code, the user indicates which part of the document contains the information that is responsive to the request.

At the completion of collecting all attachments the attachment module sends the 275 to the health plan.

Situation: Requirement for Structured Data Not Available On-line. Where the claims attachment specifications do not permit at least one of the requisite pieces of information to be sent as a document image and any of those pieces of information is not available on-line, the attachment module offers the user with two choices:

1. key the data into the system so it can be sent as structured data, or

2. send the entire set of attachments as paper.

Situation: Requirement for Data Available as Text On-line and as Paper in the Chart. Where a specific piece of information is permitted to be sent as a document image, and is available as on-line structured information but could be scanned from a document, it is to the economic benefit of the provider to send the structured data, because there are fewer manual steps and sending structured data has the potential to accelerate the processing of the claim within the health plan.

Use of LOINC Codes Not Required in the Systems that Maintain On-line Structured Clinical Data. It is not an operational requirement to precode the on-line data with LOINC codes. Just as with the paper chart. There are two alternatives. (1) The attachment module might contain a feature that maps LOINC codes to the local codes used in the systems of the CDO, or (2) a user can examine the patient's on-line records to determine which parts of the are relevant to which attachment requests.

However, if the CDO has chosen to precode the on-line data with LOINC codes the process of preparing attachments can achieve an extra level of efficiency by automating the retrieval of the data from the on-line system without having to maintain a mapping table. In any circumstance it is likely that a user would review the retrieved data before directing the attachment module to include it in the 275.

Scenario: CDO with On-line Document Images

Situation: All Required Data May Be Sent as Document Images. The attachment module determines that the information is of the category for which document images are permitted and the user determines that the CDO has document images or paper documents which satisfies the questions stated in the LOINC codes.

The user retrieves the appropriate document images from its document image management system. If the vendors of the document imaging management systems and attachment module have provided an interface, the images are transferred and converted to the format required for claims attachments automatically. Otherwise the user prints the document image and scans it into the attachment module.

The attachment module includes the images and LOINC codes in the appropriate places in the 275 transaction. If a document image contains more information than is requested by the LOINC code, the user indicates which part of the document contains the information that is responsive to the request.

Situation: Not All Required Data Available in the Document Image Management System. If the set of requested information includes information which is not available on-line and it is permitted to send this information as document images, the user retrieves or prepares the data and the attachment module scans paper documents as described above.

Situation: Structured Data Required. Where at least one of the requisite pieces of information is not permitted to be sent as a document image, the attachment module offers the user two choices:

1. key the data into the system so that it can be sent as structured data, or

2. send the entire set of attachments as paper.

At the completion of collecting all attachments the attachments system sends the 277 to the health plan.

Use of LOINC Codes Not Required in the Document Image Management System. It is not an operational requirement to precode data in the document imaging system with LOINC codes. Just as with the paper chart, a user can examine the patient's records in the Document Imaging System and determine which pages are relevant to which part of the attachments. If there is an automated interface between the attachments module and the Document Image Management System it might map between LOINC and the coding used in the Document Image Management System.

However, if the CDO has chosen to precode data in the document imaging system with LOINC codes the process of preparing attachments can achieve an extra level of efficiency by automating the retrieval of images from the document image management system without having to maintain a complex and dynamic mapping table.

Scenario: CDO with On-line Document Images and On-line Structured Data

The attachments system assembles the complete set of required information by retrieval of on-line structured data, on-line image data, and scanning of document images as described above.

At the completion of collecting all attachments the attachment system sends the 277 to the health plan.

Sub-case: Structured Data Required. Where at least one of the requisite pieces of information cannot be sent as a document image and is not available on-line, the software provides the user with one of two choices:

1. key the data into the system, or

2. send the entire set of attachments as paper.

Sub-case: Required Data Available as Structured Data and as Document Image. Where a specific piece of information may be sent as a document image, and is available both as on-line structured information and as an image, it is to the economic benefit of the provider to send the structured data, because this has the potential to accelerate the processing of the claim in the health plan.

Scenario: Health Plan, Minimal Compliance

A health plan receives 275s that have a mixture of structured data, images, or a mixture of both. Its mapping software creates human readable paper outputs by converting the structured data into human readable form. At the same time it prints the document images with headers constructed from the LOINC codes that are included with the images. The paper is then handled as it would be if it had been received from the CDO by courier.

Scenario: Health Plan with Document Image Management System

A health plan receives 275s that have a mixture of structured data, images, or a mixture of both. Its mapping software creates human readable outputs using COLD or other imaging technology by converting the structured data into human readable form. At the same time it creates COLD outputs of the document images with headers that are constructed from the LOINC codes that are included with the images. In each case the software uses the LOINC codes to construct indexes that can be used for searching the Document Image Management System for specific kinds of data. The document images are then used in adjudication exactly as they would have been if the health plan had received paper attachments and scanned them into the Document Image Management System. Some improvements in efficiency of claims adjudication, medical review, or clinical management may be possible because adjudicators can search the system for specific kinds of data in prior attachments.

Scenario: Health Plan with Aggressive Process Improvement

A health plan receives 275s that have a structured data, images, or a mixture of both. Its mapping software creates human readable outputs using COLD or other imaging technology by converting the structured data into human readable form. At the same time it creates COLD outputs of the document images with headers constructed from the LOINC codes that are included with the images. It also adds the incoming patient data to a clinical data repository. Structured data from the attachment is stored in the repository as structured data. Image data is stored as images, indexed by the associated LOINC codes.

The adjudication system attempts to auto-adjudicate the claim based on its existing rules and the structured data in the clinical data repository. Where the attachment data included document images, it enqueues the claim for manual adjudication. During manual adjudication the adjudicator has "one-click" access to the attachments relevant to specific line items.

Some additional improvements in efficiency of claims adjudication, medical review, or clinical management will be possible if the health plan chooses to build a clinical repository of data from attachments associated with claims.

Technical Approach

Description

Figure 1 shows an example of a text report. Figure 2 shows the same report as conveyed in an HL7 message. The data field OBX-3 contains a LOINC code that describes the data in OBX-5. OBX-2 contains "TX" indicating that the data type of OBX-5 is a free-form textual report (underlined in the figure). Figure 3 shows the equivalent message where the data in OBX-5 is sent as a scanned image. The data itself is incomprehensible, primary consisting of binary data reformatted as ASCII using a particularly efficient representation, Base64. For clarity most of the incomprehensible data is omitted. The complete example is in Appendix 2. Figure 4 shows the image of the text report as it would appear after being recovered from the scanned image.

General Memorial Community Hospital

DISCHARGE NOTE

PATIENT: Patient H Sample DOB: Feb 12, 1928

MEDICAL RECORD NUMBER: 6910828

STAFF PRACTITIONER NAME: C. Cure

STAFF PRACTITIONER ID:A522

DISCHARGE DATE: Aug 12, 1998

HOSPITAL DISCHARGE DX:

Metastatic breast cancer.

2. Malignant pleural effusion

HOSPITAL DISCHARGE PROCEDURES:

1. Thoracoscopy with chest tube placement and pleurodesis

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, 70-year-old female with a history of breast cancer that was originally diagnosed in the early 70's. At that time she had a radical mastectomy with postoperative radiotherapy. In the mid 70's she developed a chest wall recurrence and was treated with further radiation therapy. She then went without evidence of disease until 15 years later when she developed bone metastases with involvement of her sacroiliac joint, right trochanter, and left sacral area. She was started on Tamoxifen at that point in time and has done well until recently when she developed shortness of breath and was found to have a larger pleural effusion. This has been tapped on two occasions and has rapidly reaccumulated so she was admitted at this time for thoracoscopy with pleurodesis. Of note, her CA15-3 was 44 in early 1996 and recently was found to be 600.

HOSPITAL DISCHARGE PHYSICAL FINDINGS: Physical examination at the time of admission revealed a thin, pleasant female in mild respiratory distress. She had no adenopathy. She had decreased breath sounds three fourths of the way up on the right side. The left lung was mostly clear although there were a few scattered rales. Cardiac examination revealed a regular rate and rhythm without murmurs. She had no hepatosplenomegaly and no peripheral clubbing, cyanosis, or edema.

HOSPITAL DISCHARGE STUDIES SUMMARY: A chest x-ray showed a large pleural effusion on the right.

HOSPITAL COURSE: The patient was admitted. A CT scan was performed which showed a possibility that the lung was trapped by tumor and that there were some adhesions. The patient then underwent thoracoscopy which confirmed the presence of a pleural peel of tumor and multiple adhesions which were taken down. Two chest tubes were subsequently placed. These were left in place for approximately four days after which a TALC slurry was infused and the chest tubes were removed the following day. Because of the significant pleural peel and the trapped lungs, it is clearly possible that the pleurodesis will not be successful HOSPITAL DISCHARGE FOLLOWUP: The patient is being transferred to an extended-care facility near her home, where she will remain until she has enough strength to go home. It is possible that the fluid may reaccumulate and require repeat tapping despite the pleurodesis that was performed. She is being discharged on Tylenol with Codeine as needed for pain, Megace, and a Multivitamin. She will have a follow-up appointment with Dr. Follow in three weeks with a chest x-ray. They have been instructed to call us in the interim should there be any problems.

PROVIDER.SIGNING NAME: C. Care, M.D.

PROVIDER.SIGNING ID: A522

Figure 1. Printable Text Report.

MSH|^~\&|||||19980814053924||ORU^R01|970814053924670|P|2.3|||NE|NE

PID|||6910828^Y^C8||Sample^Patient^H|||||||||||||773789090

OBR||||11490-0^^LN^^DISCHARGE NOTE

OBX||TX|11490-0^^LN|| General Memorial Community Hospital~ DISCHARGE NOTE~~ PATIENT: Patient H Sample DOB: Feb 12, 1928~~ MEDICAL RECORD NUMBER: 6910828~~ STAFF PRACTITIONER NAME: C. Cure~~ STAFF PRACTITIONER ID:A522~~ DISCHARGE DATE: Aug 12, 1998~~ HOSPITAL DISCHARGE DX: ~ Metastatic breast cancer. ~ 2. Malignant pleural effusion~~ HOSPITAL DISCHARGE PROCEDURES: ~ 1. Thoracoscopy with chest tube placement and pleurodesis~~ HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, 70-year-old female with a history of breast cancer that was originally diagnosed in the early 70's. At that time she had a radical mastectomy with postoperative radiotherapy. In the mid 70's she developed a chest wall recurrence and was treated with further radiation therapy. She then went without evidence of disease until 15 years later when she developed bone metastases with involvement of her sacroiliac joint, right trochanter, and left sacral area. She was started on Tamoxifen at that point in time and has done well until recently when she developed shortness of breath and was found to have a larger pleural effusion. This has been tapped on two occasions and has rapidly reaccumulated so she was admitted at this time for thoracoscopy with pleurodesis. Of note, her CA15-3 was 44 in early 1996 and recently was found to be 600.~~ HOSPITAL DISCHARGE PHYSICAL FINDINGS: Physical examination at the time of admission revealed a thin, pleasant female in mild respiratory distress. She had no adenopathy. She had decreased breath sounds three fourths of the way up on the right side. The left lung was mostly clear although there were a few scattered rales. Cardiac examination revealed a regular rate and rhythm without murmurs. She had no hepatosplenomegaly and no peripheral clubbing, cyanosis, or edema.~~ HOSPITAL DISCHARGE STUDIES SUMMARY: A chest x-ray showed a large pleural effusion on the right.~~ HOSPITAL COURSE: The patient was admitted. A CT scan was performed which showed a possibility that the lung was trapped by tumor and that there were some adhesions. The patient then underwent thoracoscopy which confirmed the presence of a pleural peel of tumor and multiple adhesions which were taken down. Two chest tubes were subsequently placed. These were left in place for approximately four days after which a TALC slurry was infused and the chest tubes were removed the following day. Because of the significant pleural peel and the trapped lungs, it is clearly possible that the pleurodesis will not be successful HOSPITAL DISCHARGE FOLLOWUP: The patient is being transferred to an extended-care facility near her home, where she will remain until she has enough strength to go home. It is possible that the fluid may reaccumulate and require repeat tapping despite the pleurodesis that was performed. She is being discharged on Tylenol with Codeine as needed for pain, Megace, and a Multivitamin. She will have a follow-up appointment with Dr. Follow in three weeks with a chest x-ray. They have been instructed to call us in the interim should there be any problems.~~ PROVIDER.SIGNING NAME: C. Care, M.D.~~ PROVIDER.SIGNING ID: A522~~~ PROVIDER.SIGNING ID: A522|||||||F

Figure 2. Text Report in OBX-5.

MSH|^~\&|||||19980814053924||ORU^R01|970814053924670|P|2.3|||NE|NE

PID|||6910828^Y^C8||Sample^Patient^H|||||||||||||773789090

OBR||||11490-0^^LN^^DISCHARGE NOTE

OBX||TX|11490-0^^LN||^IM^TIFF^Base64^

SUkqANQAAABXQU5HIFRJRkYgAQC8AAAAVGl0bGU6AEF1dGhvcjoAU3ViamVjdDoAS2V5d29yZHM6~

AENvbW1lbnRzOgAAAFQAaQB0AGwAZQA6AAAAAABBAHUAdABoAG8AcgA6AAAAAABTAHUAYgBqAGUA~

YwB0ADoAAAAAAEsAZQB5AHcAbwByAGQAcwA6AAAAAABDAG8AbQBtAGUAbgB0AHMAOgAAAAAAAAAA~

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASAP4ABAABAAAAAAAAAAAB~

(681 lines omitted)

1qqQS/cFpaSVeD1QP1/SX1VJfpPSfXr+tIOKrN2aSrB8OHoH1kfz2tnPLpB/6WkksJ0w5G6WKVNe~

vSisJQdhLdQjODpbznVXXDMPdBNhVtBNpOqqtkY60qYoJxQK17cUoS0v4ijYztCapqqYUKmIUJhJ~

sKqoIO2opiqr7lupIMFBBhNQmtOIzG4naS7XsQuDBLFOP/gAgAgAAKMHAACcBgAACRcAALcYAAC4~

EwAA5RoAALQXAADyBAAAnAMAAD8LAADbEQAA5CgAAJtBAABTVQAAOHAAAOyHAAA=|||||||F

Figure 3. Scanned document image in OBX-5.

[pic]

Figure 4. Decoded image.

The figures illustrate the general approach. Where a CDO would otherwise send an attachment elements TX (free form text) format, it can choose to send it as an image instead.

When the CDO sends an image it must be formatted as a TIFF file using CCITT Group 4 encoding (see XXXX) at 200 bpi. This compression algorithm is an international standard for sending monochrome data between facsimile machines.

The binary TIFF file is then encoded using the Internet standard Base64 algorithm. Although the size of the TIFF file will vary based on the contents of the image, the binary file sizes will range from 30 to 60 kilobytes per full 8-1/2" x 11" page and proportionally smaller for partial pages. After conversion to Base64 the images will require 40 - 80 kilobytes of data per full page.

Specifications

The following specifications will be included in each HL7 LOINC code booklet where images are permitted.

Where the value table in section 4 indicates that either the CDED or TX data type is allowed in OBX-2 the value in OBX-5 may contain an image of a medical record document meeting the following specifications.

1. The image may contain a partial page, a full page, or multiple pages.

2. The contents of the image must be information that is described by the LOINC code in OBX-4. If the image contains more information than that which is specified by the LOINC code, the portion of the image that is described by the LOINC code must be outlined or otherwise unambiguously denoted.

3. The image must be a black and white (2-color) image scanned at 200 pixels per inch in the format of a TIFF file with the CCITT Group 4 subtype.[4],[5]

When an image is sent, OBX-2 must contain the value ED which stands for encapsulated data. The components of OBX-5 must be as described below.

1. The first component, source application, must be null.

2. Component 2, type of data, must contain IM, indicating image data.

3. Component 3, data subtype, must contain TIFF

4. Component 4, encoding, must contain Base64

5. Component 5, data, contains the TIFF file encoded using the Base64 algorithm as defined in the MIME Internet standard, RFC-1521.

When an image is sent all fields of OBX that follow OBX-5 must be null except:

1. OBX-11 must be included.

2. OBX-14 may be null if the clinically relevant date and time is included in the image. Otherwise it must be included.

Design Considerations

This section documents alternatives that were considered in the development of this specification.

Choice of Image Format

Consideration was given to other image formats including Graphics Interchange Format (GIF), the Joint Picture Expert Group (JPEG), and DICOM. GIF was eliminated because (a) it is proprietary, and (b) it is suitable primarily for graphics that are combinations of a few colors. Documents are either monochrome or contain colors that vary continuously, such as photographs. The incremental benefit of GIF was minimal when compared the legal considerations and the need for all health plans to implement all specified image formats.

JPEG is not an appropriate format for anything except photographs. As shown in Appendix 1, documents that are compressed with JPEG exhibit artifacts that reduce the clarity unless the JPEG files are created at compression levels that require approximately six times as much space as the chosen TIFF algorithm. Furthermore, a Joint Picture Experts Group is working on a revised specification, originally named JPEG-2000, which has more compression and fewer artifacts than the current standard. The decision not to include JPEG will be revisited based on specific requirements and use cases as additional attachments are developed. Examples of use cases that might justify including JPEG are attachments to support dental X-rays or certification for cosmetic surgery.

DICOM images are complex objects intended to support the image quality required for diagnostic evaluation, extensive manipulation, and to provide morphological, spatial, and time orientation suitable for complex manipulations. The programs that create and display DICOM images are expensive and complex to implement. Given the requirement that all payers must implement all image formats, the committee did not believe that the technological cost and risk of including DICOM images was justiried.

The CCITT Group 4 format is highly compressed and its limitations are easy to explain to healthcare professionals who do not have experience with digital imaging, because everyone has experience using fax machines.

Another format with similar qualifications is CCITT Group 3. It is identical to CCITT Group 4 except that it contains overhead characters to recover from communications errors that are common when fax machines communicate directly over analog telephone lines. The design of X12 and HL7 message assumes that communications errors are corrected by lower layer protocols, so the overhead characters serve no useful purpose for attachments.

Sending Raw Images in BIN Segments

A case can be made for sending images as binary data in BIN segments without the superstructure of the HL7 ORU message. Images sent in this manner would require approximately 25% less space. This option has difficulties because claims attachments transactions are a five-level hierarchy:

1. The Entire 275

2. The xxx loop in the 275

3. A complete attachment

4. An attachment element

5. A part of an attachment element

A single BIN segment contains levels 3, 4 and 5. The relationship between levels 4 and 5 is always represented by the relationship between OBR and OBX segments in the HL7 ORU message. The relationship between levels 3 and 4 is represented by repeating OBR segments in the HL7 ORU message. It is possible that a single complete attachment could contain multiple elements, some of which are structured and some of which may be sent using an image. For complex attachments, such as the Emergency Department attachment, it is even possible that a single attachment element could contain a mixture of parts that require structured data and parts that permit images.

The structure of the 275 does not permit the creation of multiple consecutive BIN segments, nor does it permit the use of LOINC codes in appropriate to level 5 in the associated STC segment.

While it would be possible to construct a situational specification that allowed images to be sent in BIN segments without the ORU message for selected cases, the complexity of implementing, maintaining and testing mappings to meet such a specification is prohibitive.

Appendix 1: Alternative Image Formats

|[pic] |A page from an X12N Implementation Guide was printed on a LaserJet printer, a |

| |handwritten annotation was added, and then the page was scanned using a $150 |

| |Epson scanner and the software that was provided with the scanner. Various |

| |scanner settings and output files were created. A portion was extracted from |

| |each of the sample files to show how image would look after compression and |

| |reexpansion. |

|Image Type/ |Size |Sample |

|characteristics | | |

|JPEG |55KB |[pic] |

|Image-02.JPG | | |

|72 bpi | | |

|489x687x 24 bits | | |

|aggressive compression | | |

|JPEG |52KB |[pic] |

|Image-01.JPG | | |

|72 bpi | | |

|489x687x 8 bits | | |

|aggressive compression | | |

|TIFF |55KB |[pic] |

|Image-04CCITTgroup3.TIF | | |

|96 bpi | | |

|JPEG |192KB |[pic] |

|Image-03compress.JPG | | |

|72 dpi | | |

|very strong JPEG compression| | |

|JPEG |326KB |[pic] |

|Image-04.JPG | | |

|200 dpi | | |

|TIFF |414KB |[pic] |

|Image-04LZW.TIF | | |

|Image-03.JPG |735KB |[pic] |

|300 dpi | | |

|very little compression (90)| | |

Appendix 2: Complete Example HL7 Message

This appendix contains the complete sample message, so that the inquisitive reader who has a soft copy can copy and paste it into software that decodes the message and image. It is not intended by be viewed on screen or in a printed document.

MSH|^~\&|||||19980814053924||ORU^R01|970814053924670|P|2.3|||NE|NE

PID|||6910828^Y^C8||Sample^Patient^H|||||||||||||773789090

OBR||||11490-0^^LN^^DISCHARGE NOTE

OBX||TX|11490-0^^LN||^IM^TIFF^Base64^

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-----------------------

[1] ASC X12N Implementation Guide for Use of the 275 Transaction (004020) Additional Information to Support a Health Care Claim or Encounter, subcommittee X12N of Accredited Standards Committee X12.

[2] Health Level Seven (HL7) Implementation Guide for Additional Information to Support a Healthcare Claim or Encounter, Version 1.0.

[3] LOINC codes are copyrighted by and LOINC is a service mark of the Regenstrief Institute and LOINC Committee, 1001 West 10th Street RG-5, Indianapolis, IN 46202. 317/630-7433. Available under a free license from ( HL7/termcode/ loinclab/). The LOINC Code System is described in Forrey AW, McDonald CJ, DeMoor G, Huff SM, Leavelle D, Leland D, et.al. "Logical Observation Identifier Names and Codes (LOINC) database: a public use set of codes and names for electronic reporting of clinical laboratory test results." Clinical Chemistry 1996;42:81-90

[4] TIFF Revision 6.0 Final, June 3, 1992, published by Adobe Developers Association; 345 Park Avenue; San Jose, CA 95110-2704 (see ).

[5] Recommendation T.6 (11/88) - Facsimile coding schemes and coding control functions for Group 4 facsimile apparatus, International Telecommunication Union (ITU), Place des Nations, CH-1211 Geneva 20, Switzerland (). These specifications were originally published before the ITU changed its name from Comite Consultatif International de Telegraphique et Telephonique (CCITT) in 1992 and are still commonly referred to as CCITT recommendations.

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