Medical Record Committee Meeting



Medical Record Committee Meeting

Atlanta, Georgia

28 –29 September, 1999

Attendees:

Tuesday: Wayne Tracy, Liora Altschuler, Sharon Kraus, Craig Luce, Mike Ball, Harry Rhodes, Ed Jones, Jeff Stack, Todd Cestari, Hank von Meeberg, Craig Luce, Anne Shanney, Sharon Kraus, Chris Stahlecker, Shahn Campbell, Dick Harding.

Wednesday: Daniel Huffman, Bas Van Poppel, Joseph Bapdist, Don Carlson, Todd Cestari, Jon Berglund, John Dulcey, M.D>, Mike Ball, Harry Rhodes, Anne Shanney, David Means, Anita Benson, Art Bechtel, Wayne Tracy

Wednesday JWG with XML SIG: Vassil Petchev, Harry Rhodes, Rachael Sokolwski, Mark Israel, Mike Ball, Daniel Huffman, Liora Altschuler, Bob Dolin, Carl Adler, Siu Wing Tong, George Beeler, Steve Kordik, Mohamed Ourani, Dale Frye, Sandy Boyer, Thanos Tsiolis, Joseph Baptist, John Dulcey, MD, Art Bechtel, Kai U. Heitmann, Mike Cassidy, Helen Fallahi, Karen Keeler, Laura Megus, Helen Gurericy, Bob Moe, Calvin Beebe, John Beach, Wayne Tracy, Anne Shanney

Highlights:

• Election of Harry Rhodes as co-chair

• Joint Working Group with Patient Referral/Scheduling resulted in a request for a proposal of Chart Tracking requirements to be discussed at the January 2000 Working Group Meeting.

• Joint Working Group with XML SIG resulted in the agreement of the Medical Record/ Information Management Technical Committee to sponsor the ballot for HL7 acceptance of the PRA message architecture.

• Extension of 2.4 to include changes in the message definitions for Trigger Events T07, T08, T09, and T10.

• Extension of Version 2.4 and the RIM to include a new field, Version ID, as an attribute of the Object class Clinical_document_header.

Tuesday Morning:

Election of co-chair: Harry Rhodes, AHIMA, had been previously nominated, and Michael Ball offered himself as an additional candidate. Wayne described the responsibilities of the co-chair and the time commitments during the meeting and between the meetings. Both candidates described their backgrounds, and John Quinn conducted the election.

During the election ballot counting, the attendees introduced themselves. Wayne described procedures: New business is requested in both hard copy and electronic form. This assures that the larger membership, not merely attendees, have access to the presentation materials. The agenda was reviewed and approved.

New agenda was proposed: Discussion of pre-meeting with ASTM, PRA message review, Chart tracking proposal, consents, and incremental requirements within the scope of existing Medical Record chapter. Wednesday will include a joint session with Patient Referral/Scheduling in the morning and with the SGML in the latter part of the afternoon. Wayne then requested additional items or change of order of agenda items from the meeting. Liora Altschuler requested that the PRA segment be discussed first, so she might be present.

Wayne requested that we complete the discussion of the ASTM pre-meeting before turning to the issues of the PRA message. An informal meeting was held on Tuesday with the new ASTM E31.22 chair-elect. Background: Medical Record Document Messaging has been part of the HL7 Standard since 1994, with numerous installed interfaces using the Standard. ASTM requested permission to publish documentation for its own standard for transmission of voice data. The Chapter 9 data type table was incorporated into the ASTM document, with the removal of AU – Audio data type, and the inclusion of a z-segment to support audio transmission. Both first and second refusals of permission were based on the overlap which would have created an alternate standard, the usage of the reserved character for local extensions of the standard, and concern that a partial reference to the HL7 Standard, without reference to the complete Standard, would result in incorrect implementations. New ASTM chair requested background, was provided with copy of letter and explanation. Informal agreement was reached for ASTM to discontinue effort to publish a separate standard, with encouragement to participate in HL7 meetings, to address and remedy any failings of the Standard. There was discussion of the reasons why the AU data type does not specifying a technology. Current industry efforts are varied, but each is self-describing, consequently the Standard need not specify. There is additional concern that audio transmission technology is not yet mature, and specification of a technology may be immediately obsolete. Discussion of resolution of differences between ASTM and HL7 included recommendations that representatives of each organization attend meetings of the other organization.

Liora Altshuler conducted discussion of the XML SIG’s submission of a formal proposal for ballot for inclusion as normative material in the Standard. Wayne described the committee balloting process, which is prior to the general balloting process. List was created for persons interested in balloting, since committee-level balloting is not limited to formal members, but includes interested parties. Wayne described the ANSI process for acceptance of a Standard, including HL7.

Wayne described meeting with Bob Dolin from the SGML SIG.

Liora described the contents of the TSC proposal packet. There are four sections:

1. Cover letter for arguments for acceptance, including data content described as total overlap with the Version 3 RIM.

2. The framework document for the architecture itself.

3. Discussion of conceptual approach, which is proposal to harmonize the PRA with the version 3 MDM framework.

4. A bibliography of XML/SGML usage and references.

It was observed that the RIM elements utilized by PRA are under Medical Record stewardship. Difference in scope was described as the principal difference between PRA and Chapter 9 content. There followed some discussion and disagreement as to the extent of the difference.

Wayne discussed inclusion of OBX segment, historically the only available, with the observation that the PRA message offers for the first time a three-level structure, which is hierarchically more robust than the existing Chapter 9 structure.

Wayne provided a description of OBX expansions under consideration for the CDC: gross, microscopic, interpretation, diagnosis. There has been development of LOINC codes for each of these section descriptions, but they are still being sent as individual OBX segments. The PRA message hierarchy presents a way to overcome this architectural limitation of the existing Standard.

Following the break, the discussion moved to an overview of the RIM contributions of Chapter 9. The process for RIM harmonization was explained. Discussion then turned to content of the medical record document domain vis-a-vis the PRA.

| Ballot Motion: Shall the MR committee evaluate the PRA message for adoption of this architecture as V3 methodology for documents? |

|For: 8 |

|Against: 0 |

|Abstain: 1 |

One outcome of the RIM Harmonization is a number of changed definitions for clarification identified during PRA development:

Addendum: An appendage to an existing document that contains supplemental information. The parent document remains in place and its content is unaltered. It is defined operationally as a document containing a non-null value in the Parent Doc ID field.

Document completion table was discussed for understanding of different states of document: Authenticated corresponds to the concept of attestation as used in the United States to refer to verification of a medical document as complete and ready for submission to a governmental payor.

Pre-authenticated and Legally authenticated states also exist in the 2.3.1 Standard.

Replacement document: A document that replaces an existing document. The original document becomes obsolete, but is still retained in the system for historical reference. This replacement employs the same document ID as the document it replaced.

A new topic was raised by Harry Rhodes for discussion: Has the Standard covered the case of a document “closed” by committee when the person who is legally responsible for authentication is unavailable, either through death or some other compelling reason. What is the anticipated behavior of documents in that condition? Is this another authentication status?

E.G.. Transcription linked to a chart deficiency tracking system may identify documents which are pre-authenticated, but, due to unavailability of the originator, will never be authenticated, but require some form of closure for operational purposes.

It was noted that a previously unmet PRA requirement for a document.state (original, replacement) has resulted in change to the RIM attributes for documents.

Concern was expressed that the PRA architecture may be unacceptable if it can’t handle other than human-readable text: the message itself is not human-readable, but implementers are working with non-text documents, and the Standard permits the use of non-text documents:

e.g. CAT scan of 10 MB, with header of ................
................

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