mcss hl7 implementation guide for e-path reporting · mcss . hl7 implementation guide for e-path...
TRANSCRIPT
M C S S
HL7 Implementation Guide for E-path Reporting
Minnesota Cancer Surveillance System PO Box 64882
St Paul, MN 55164-0882
Version 5.0 8/1/2012 2
Chapter .................................................................................................................................................................................................................. 4 1 .............................................................................................................................................................................................................................. 4
Introduction to E-path ......................................................................................................................................................................................... 4 Required Data Items for E-path Reporting ........................................................................................................................................... 5 Refer to Appendix B: HL7 Structure and Required Data items for complete standards and description of the requirements for submitting pathology reports as an HL7 message. ................................................................................................................................ 12 Refer to Appendix C: NAACCR Standards for Cancer Registries, Volume II, Chapter 6 ................................................................ 12 Pathology Laboratory Electronic Reporting: Items, Formatting, Recommendations. (Version 1.1; September, 2000) for complete standards and description of the requirements for submitting pathology reports as an ascii file. .................................. 12
Chapter ................................................................................................................................................................................................................ 14 2 ............................................................................................................................................................................................................................ 14
Use Case #1: Submission of pathology reports to the MCSS ........................................................................................................................... 14 #1A. Pathology Laboratory completes the MCSS E-path Reporting: Laboratory Assessment. .......................................... 14 #1B. Pathology Laboratory creates an HL7 message of pathology reports. ............................................................................ 14 Responsible Party: Pathology Laboratory .............................................................................................................................................. 14 #1C. HL7 Message is encrypted and sent to MDH. ......................................................................................................................... 16 Responsible Party: Pathology Laboratory .............................................................................................................................................. 16
Chapter ................................................................................................................................................................................................................ 17 3 ............................................................................................................................................................................................................................ 17
Use Case #2: Transfer of files to the MCSS database ...................................................................................................................................... 17 #2A. Prepare file for loading into MCSS database. ......................................................................................................................... 17 Responsible Party: VisionShare ............................................................................................................... Error! Bookmark not defined. #2B. Load ascii formatted file into the mcss pending database. .................................................. Error! Bookmark not defined. Responsible Party: MCSS IT .................................................................................................................... Error! Bookmark not defined.
Chapter ................................................................................................................................................................................................................ 18 4 ............................................................................................................................................................................................................................ 18
Use Case #3: Processing of Electronic Pathology Reports at the MCSS .......................................................................................................... 18 #3A. Update Path-number log to ensure all reports are submitted. ........................................................................................... 18 #3B. Identify pathology reports that are potentially reportable to the MCSS. .......................................................................... 19 #3C. Notify MCSS staff of results of submission and pre-processing. ....................................... Error! Bookmark not defined. #3D. Determine final reportability of pathology reports. ............................................................................................................... 19 Appendix A. MCSS Electronic Pathology Reporting: Laboratory Assessment ...................................................................... 21 1. Type and version of Laboratory Information System (LIS) ................................................................................................ 21 2. Method of submitting pathology reports electronically ...................................................................................................... 21 3. Method of reporting Text information ..................................................................................................................................... 21 4. Method of identifying and submitting late reports ............................................................................................................... 21 5. Method of reporting amended/supplemental reports .......................................................................................................... 21 6. Laboratory Pathology Report Types ........................................................................................................................................ 22 Prefix ............................................................................................................................................................................................................ 22 Report Type: Definition/Comments ......................................................................................................................................................... 22 Recycle numbers annually? ...................................................................................................................................................................... 22 Comments: ................................................................................................................................................................................................ 22 Laboratory Assessment of Required Data Items.............................................................................................................................. 23 Appendix B. HL7 Structure and Required Data Items for E-path Reporting ............................................................................. 25 The following segments relate to the HL7 Batch Protocol: 1) BHS - Batch Header, 2) BTS -Batch Trailer, 3) FHS - File Header, and 4) FTS - File Trailer. The BTS segment contains a field, BTS-3-batch totals, which may have one or more totals drawn from fields within the individual messages. The method for computing such totals resides with the sending facility. ........... Error! Bookmark not defined. 4.3.1 File Header (FHS) Segment .................................................................................................................................................... 26 4.3.2 File Trailer (FTS) ....................................................................................................................................................................... 26 4.3.3 Batch Header (BHS) Segment ............................................................................................................................................... 26 4.3.4 Batch Trailer (BTS) Segment ................................................................................................................................................. 26 3.1.1 Message Header (MSH) Segment ......................................................................................................................................... 26 3.2.1 Patient Identification (PID) Segment .................................................................................................................................... 27 3.2.1 Next of Kin/Associated Parties (NK1) Segment ................................................................. Error! Bookmark not defined. 3.3.1 Common Order (ORC) Segment............................................................................................................................................ 27 3.3.2 Observation Request Segment (OBR) ................................................................................................................................. 27 3.3.3 Observation/Result (OBX) Segment. ................................................................................................................................... 27 3.3.4 NOTES AND COMMENTS (NTE) SEGMENT ...................................................................................................................... 27 7 Data Types used in this Implementation..................................................................................................... Error! Bookmark not defined. Appendix C: ASCII Record Layout and Required Data Items for E-path Reporting .............................................................. 28 NAACCR Standards for Cancer Registries, Volume II, Chapter 6 - Pathology Laboratory Electronic Reporting: Items, Formatting, Recommendations. (Version 1.1; September, 2000) ...................................................................................................... 28
Version 5.0 8/1/2012 3
Chapter IV. B.: Pathology Laboratory Data Table ........................................................................................................................... 28 Appendix D: Table Structures .............................................................................................................................................................. 29 Appendix D: Email Messages ...................................................................................................................................................................... 39 Incomplete ASCII Record (critical data item(s) missing from a record.) ....................................................................... 39 Bad ASCII Record (a non-standard ascii record is identified.) ......................................... Error! Bookmark not defined. Appendix E. File structure for epr files ........................................................................................................................................................ 40
Version 5.0 8/1/2012 4
Introduction to E-path Purpose, Definitions, and Overview
Electronic submission of laboratory-based reports for cancer reporting, e-path, has become a popular method for laboratories to meet their reporting requirements for cancer diagnoses. E-path, using standard messaging and file structures, will “greatly increase the efficiency and consistency with which laboratories and central registries can meet reporting and data collection requirements”.1
The MCSS offers e-path reporting for laboratories that can send encrypted files through our secure web page or using PhinMS transfer technology from the CDC. The files may be either HL7 or ascii pipe-delimited files.
Required data items, standard message and file formats are discussed in detail within this document.
1 “Pathology Laboratory Electronic Reporting Recommendations …: Version 2.0 February 2009. See http://www.naaccr.org/filesystem/pdf/Standards_Volume_V_version_2.2_draftB_revised_February_2009.pdf
Chapter
1
Version 5.0 8/1/2012 5
Required Data Items for E-path Reporting The MCSS requires specific data items when cancer cases are being reported via a pathology report. These data items are the same, whether submitting a printed copy of the pathology report or an electronic version and include:
1. Pathology Facility ID Number (The laboratory submitting the report; it may be different that #11, the facility that obtained the specimen.)
2. Laboratory Name 3. Patient Name 4. Patient Address 5. Date of Birth (or path-age at specimen) 6. Social Security Number 7. Sex 8. Medical Record Number 9. Path-Slide/Pathology Report Number 10. Physician (Attending) 11. Facility ID Number (The facility that obtained the specimen) 12. Pathologist 13. Date of Specimen Collection 14. Text of pathology report (including clinical history, nature of specimen, gross
pathology, microscopic pathology, final diagnosis, staging, parameters, comments, addenda)
Specific data item requirements are described in Table 1, “MCSS Data Item Requirements for Electronic Pathology Reporting”. The data items marked “R” in the MCSS opt column are the required dataset. These data items must be included in the submission if the data is available in the facility. Additionally, Minnesota Rules Chapter 4606 requires that “as much as is known” of additional patient information fields be submitted to the MCSS. These are marked as “RE”. Data items marked “R” and “RE” is nearly always available in the medical records or business office of the hospitals where the pathology laboratories are located or on the pathology specimen requisition slip. The additional data items must be submitted if they are available in the laboratory or in the hospital patient data system. If the data item is not available within the facility, the MCSS will issue a waiver, indicating that the data item does not need to be submitted.
Version 5.0 8/1/2012 6
Table 1: MCSS Data Item Requirements for Electronic Pathology (epath) Reporting
HL7 Segm
ent
HL7 Seq
HL7 Item #
HL7 ELEMENT NAME NAACCR
OPT
MCSS
opt*
NAACCR Item #
NAACCR Item Name old Epath item #
MSH 1 00001 Field separator R R MSH 2 00002 Encoding characters R R MSH 3 00003 Sending application O O MSH 4 00004 Sending facility R R 7020, 7030,
7040, 7050, 7060
Path Lab Name, Path Lab Addr-No & St, Path Lab Addr-
City, Path Lab Addr-State, and Path Lab Addr-Postal Code
4-8
MSH 5 00005 Receiving application O O MSH 6 00006 Receiving facility O O MSH 7 00007 Date/Time of message R R MSH 8 00008 Security O O MSH 9 00009 Message type R R MSH 10 00010 Message control ID R R MSH 11 00011 Processing ID R R MSH 12 00012 Version ID R R MSH 13 00013 Sequence number O O MSH 14 00014 Continuation pointer O O MSH 15 00015 Accept acknowledgment
type O O
MSH 16 00016 Application acknowledgment type
O O
MSH 17 00017 Country code O O MSH 18 00692 Character set O O MSH 19 00693 Principal language of
message O O
MSH 20 01317 Alternate character set handling scheme
NA NA
PID 1 00104 Set ID - PID O O PID 2 00105 Patient ID (External) B B PID 3 00106 Patient identifier list R R 20, 2300,
2320 Patient ID Number, Social
Security Number, and Medical Record Number
22, 20
PID 4 00107 Alternate patient ID - PID
B B
PID 5 00108 Patient name R R 2230, 2240, 2250
Name-Last, Name-First, and Name-Middle
10-12
PID 6 00109 Mother's maiden name O RE PID 7 00110 Date/time of birth RE R 240 Birth Date 18 PID 8 00111 Sex RE RE 220 Sex 21 PID 9 00112 Patient alias O RE 2280 Name-Alias PID 10 00113 Race RE RE 160 Race 1 PID 11 00114 Patient address RE RE 70, 80, 100,
2330 Addr at DX-City, Addr at DX-
State, Addr at DX Postal Code, and Addr at DX-No & Street
14-16, 13
PID 12 00115 County code B B PID 13 00116 Phone number - home O O 2360 Telephone 17 PID 14 00117 Phone number - O O
Version 5.0 8/1/2012 7
business PID 15 00118 Primary language O O PID 16 00119 Marital status O O 150 Marital Status PID 17 00120 Religion O O 260 Religion PID 18 00121 Patient account number O O PID 19 00122 SSN number - patient B B PID 20 00123 Driver's license number
- patient O O
PID 21 00124 Mother's identifier O O PID 22 00125 Ethnic group O RE PID 23 00126 Birth place O O PID 24 00127 Multiple birth indicator NA NA PID 25 00128 Birth order NA NA PID 26 00129 Citizenship NA NA PID 27 00130 Veterans military status NA NA PID 28 00739 Nationality O RE PID 29 00740 Patient death date and
time O RE
PID 30 00741 Patient death indicator O RE 1760 Vital Status NK1 1 00190 Set ID - NK1 R R NK1 2 00191 Name O O NK1 3 00192 Relationship O O NK1 4 00193 Address O O NK1 5 00194 Phone number O O NK1 6 00195 Business phone number NA NA NK1 7 00196 Contact role NA NA NK1 8 00197 Start date NA NA NK1 9 00198 End date NA NA NK1 10 00199 Next of kin/AP job title NA NA NK1 11 00200 Next of kin/AP job
code/class NA NA
NK1 12 00201 Next of kin/AP employee number
NA NA
NK1 13 00202 Organization name - NK1
NA NA
NK1 14 00119 Marital status NA NA NK1 15 00111 Sex NA NA NK1 16 00110 Date/time of birth NA NA NK1 17 00755 Living dependency NA NA NK1 18 00145 Ambulatory status NA NA NK1 19 00129 Citizenship NA NA NK1 20 00118 Primary language NA NA NK1 21 00742 Living arrangement NA NA NK1 22 00743 Publicity code NA NA NK1 23 00744 Protection indicator NA NA NK1 24 00745 Student indicator NA NA NK1 25 00120 Religion NA NA NK1 26 00746 Mother's maiden name NA NA NK1 27 00739 Nationality NA NA NK1 28 00125 Ethnic group NA NA NK1 29 00747 Contact reason NA NA NK1 30 00748 Contact person's name NA NA
Version 5.0 8/1/2012 8
NK1 31 00749 Contact person's telephone number
NA NA
NK1 32 00750 Contact person's address
NA NA
NK1 33 00751 Next of kin/AP's identifiers
NA NA
NK1 34 00752 Job status NA NA NK1 35 00113 Race NA NA NK1 36 00753 Handicap NA NA NK1 37 00754 Contact person social
security # NA NA
PV1 1 00131 Set ID – PV1 O O PV1 2 00132 Patient Class R RE PV1 3 00133 Assigned Patient
Location NA NA
PV1 4 00134 Admission Type O O PV1 5 00135 Preadmit Number NA NA PV1 6 00136 Prior Patient Location NA NA PV1 7 00137 Attending Doctor RE RE 2460 Physician Managing PV1 8 00138 Referring Doctor RE RE 2470 Physician Follow-up PV1 9 00139 Consulting Doctor NA NA PV1 10 00140 Hospital Service NA NA PV1 11 00141 Temporary Location NA NA PV1 12 00142 Preadmit Test Indicator NA NA PV1 13 00143 Re-admission Indicator NA NA PV1 14 00144 Admit Source NA NA PV1 15 00145 Ambulatory Status NA NA PV1 16 00146 VIP Indicator NA NA PV1 17 00147 Admitting Doctor NA NA PV1 18 00148 Patient Type NA NA PV1 19 00149 Visit Number NA NA PV1 20 00150 Financial Class NA NA PV1 21 00151 Charge Price Indicator NA NA PV1 22 00152 Courtesy Code NA NA PV1 23 00153 Credit Rating NA NA PV1 24 00154 Contract Code NA NA PV1 25 00155 Contract Effective Date NA NA PV1 26 00156 Contract Amount NA NA PV1 27 00157 Contract Period NA NA PV1 28 00158 Interest Code NA NA PV1 29 00159 Transfer to Bad Debt
Code NA NA
PV1 30 00160 Transfer to Bad Debt Date
NA NA
PV1 31 00161 Bad Debt Agency Code NA NA PV1 32 00162 Bad Debt Transfer
Amount NA NA
PV1 33 00163 Bad Debt Recovery Amount
NA NA
PV1 34 00164 Delete Account Indicator NA NA PV1 35 00165 Delete Account Date NA NA PV1 36 00166 Discharge Disposition NA NA PV1 37 00167 Discharged to Location NA NA
Version 5.0 8/1/2012 9
PV1 38 00168 Diet Type NA NA PV1 39 00169 Servicing Facility NA NA PV1 40 00170 Bed Status NA NA PV1 41 00171 Account Status NA NA PV1 42 00172 Pending Location NA NA PV1 43 00173 Prior Temporary
Location NA NA
PV1 44 00174 Admit Date/Time NA NA PV1 45 00175 Discharge Date/Time NA NA PV1 46 00176 Current Patient Balance NA NA PV1 47 00177 Total Charges NA NA PV1 48 00178 Total Adjustments NA NA PV1 49 00179 Total Payments NA NA PV1 50 00180 Alternate Visit ID NA NA PV1 51 01226 Visit Indicator NA NA PV1 52 01274 Other Healthcare
Provider NA NA
ORC 1 00215 Order Control R R ORC 2 00216 Placer Order Number NA NA ORC 3 00217 Filler Order Number NA NA ORC 4 00218 Placer Group Number NA NA ORC 5 00219 Order Status NA NA ORC 6 00220 Response Flag NA NA ORC 7 00221 Quantity/Timing NA NA ORC 8 00222 Parent NA NA ORC 9 00223 Date/Time of
Transaction NA NA
ORC 10 00224 Entered By NA NA ORC 11 00225 Verified By NA NA ORC 12 00226 Ordering Provider NA NA ORC 13 00227 Enterer’s Location NA NA ORC 14 00228 Call Back Phone
Number NA NA
ORC 15 00229 Order Effective Date/Time
NA NA
ORC 16 00230 Order Control Code Reason
NA NA
ORC 17 00231 Entering Organization NA NA ORC 18 00232 Entering Device NA NA ORC 19 00233 Action By NA NA ORC 20 01310 Advanced Beneficiary
Notice Code NA NA
ORC 21 01311 Ordering Facility Name R R 7200 Work Facility Name 34 ORC 22 01312 Ordering Facility
Address RE RE 7210, 7220,
7230, 7240 Work Fac Addr-No & St, Work
Fac Addr-City, Work Fac Addr-State, and Work Fac-Postal
Code
35-38
ORC 23 01313 Ordering Facility Phone Number
RE RE 7250 Work Facility-Telephone 39
ORC 24 01314 Ordering Provider Address
RE RE 7140, 7150, 7160, 7170
Order Client/Phys-Street, Order Client/Phys-City, Order Client/Phys-State, andOrder
Client/Phys-PostCod
28-31
Version 5.0 8/1/2012 10
OBR 1 00237 Set ID – OBR R R OBR 2 00216 Placer Order Number O O OBR 3 00217 Filler Order Number+ R R 7090 Slide Report Number 23 OBR 4 00238 Universal Service ID R R OBR 5 00239 Priority NA NA OBR 6 00240 Requested Date/Time NA NA OBR 7 00241 Observation Date/Time
# R R 7320 Path-Date Spec Collection 46
OBR 8 00242 Observation End Date/Time #
NA NA
OBR 9 00243 Collection Volume * NA NA OBR 10 00244 Collector Identifier * NA NA OBR 11 00245 Specimen Action Code * NA NA OBR 12 00246 Danger Code NA NA OBR 13 00247 Relevant Clinical Info. NA NA OBR 14 00248 Specimen Received
Date/Time * RE RE
OBR 15 00249 Specimen Source * RE RE OBR 16 00226 Ordering Provider RE RE 2480 Primary Surgeon OBR 17 00250 Order Callback Phone
Number O O 7180 Order Client Phone 32
OBR 18 00251 Placer Field 1 NA NA OBR 19 00252 Placer Field 2 NA NA OBR 20 00253 Filler Field 1 + NA NA OBR 21 00254 Filler Field 2 + NA NA OBR 22 00255 Results Rpt/Status
Chng-Date/Time + RE RE
OBR 23 00256 Charge to Practice + NA NA OBR 24 00257 Diagnostic Serv Sect ID NA NA OBR 25 00258 Result Status + RE RE OBR 26 00259 Parent Result + O O OBR 27 00221 Quantity/Timing NA NA OBR 28 00260 Result Copies To O O OBR 29 00261 Parent * O O OBR 30 00262 Transportation Mode O O OBR 31 00263 Reason for Study O O OBR 32 00264 Principal Result
Interpreter + R R 7260, 7270,
7280, 7290, 7300, 7310
Pathologist Last Name, Pathologist First Name,
Pathologist Middle Name, Pathologist Name Suffix,
Pathologist Lic Number, and Pathologist Lic State
40-45
OBR 33 00265 Assistant Result Interpreter +
O O
OBR 34 00266 Technician + O O OBR 35 00267 Transcriptionist + NA NA OBR 36 00268 Scheduled Date/ Time + NA NA OBR 37 01028 Number of Sample
Containers * NA NA
OBR 38 01029 Transport Logistics of Collected Sample *
NA NA
OBR 39 01030 Collector's Comment* NA NA OBR 40 01031 Transport Arrangement NA NA
Version 5.0 8/1/2012 11
Responsibility OBR 41 01032 Transport Arranged NA NA OBR 42 01033 Escort Required NA NA OBR 43 01034 Planned Patient
Transport Comment NA NA
OBR 44 00393 Procedure Code RE RE OBR 45 01316 Procedure Code
Modifier RE RE
OBX 1 00569 Set ID-OBX R R OBX 2 00570 Value type R R OBX 3 00571 Observation identifier* R R OBX 4 00572 Observation sub-ID RE RE OBX 5 00573 Observation value* R R 7340, 7350,
7360, 7370, 7380, 7390, 7400, 7410, 7420, 7430, 7440, 7450, 7460, 7470
Path-SNOMED Code(s), Path-SNOMED Version, Path-ICD-CM codes, Path-ICD Version
Number, Path-CPT codes, Path-CPT Code Version, Path-
Text Diagnosis, Path-Clinical History, Path-Nature of Specimen, Path-Gross Pathology, Path-Micro
Pathology, Path-Comment Section, Path-Suppl Reports,
and Path-Final Diagnosis
48-61
OBX 6 00574 Units RE RE OBX 7 00575 Reference ranges O O OBX 8 00576 Abnormal flags O O OBX 9 00577 Probability O O OBX 10 00578 Nature of abnormal test O O OBX 11 00579 Observation result
status RE RE 7330 Path—Result Status 47
OBX 12 00580 Date last Obs normal values
O O
OBX 13 00581 User defined access checks
O O
OBX 14 00582 Date/time of the observation
O O
OBX 15 00583 Producer's ID O O OBX 16 00584 Responsible observer O O OBX 17 00936 Observation method O O NTE 1 00096 Set ID – NTE O O NTE 2 00097 Source of Comment O O NTE 3 00098 Comment O O NTE 4 01318 Comment Type O O FHS 1 00067 File field separator R R FHS 2 00068 File encoding characters R R FHS 3 00069 File sending application O O FHS 4 00070 File sending facility R R FHS 5 00071 File receiving application O O FHS 6 00072 File receiving facility O O FHS 7 00073 File creation date/time R R
Version 5.0 8/1/2012 12
FHS 8 00074 File security O O FHS 9 00075 File name/ID/type RE RE FHS 10 00076 File comment O O FHS 11 00077 File control ID O O FHS 12 00078 Reference file control ID O O FTS 1 00079 File batch count R R FTS 2 00080 File trailer comment O O BHS 1 00081 Batch field separator R R BHS 2 00082 Batch encoding
characters R R
BHS 3 00083 Batch sending application
O O
BHS 4 00084 Batch sending facility R R BHS 5 00085 Batch receiving
application O O
BHS 6 00086 Batch receiving facility O O BHS 7 00087 Batch creation date/time R R BHS 8 00088 Batch security O O BHS 9 00089 Batch name/ID/type O O BHS 10 00090 Batch comment O O BHS 11 00091 Batch control ID O O BHS 12 00092 Reference batch control
ID O O
BTS 1 00093 Batch message count R R BTS 2 00094 Batch comment O O BTS 3 00095 Batch totals R R
*MCSS Option Key:
R Required Laboratory must send this information or obtain a waiver from the MCSS. RE Required field but can be left Empty
Laboratory must send this information if it is in their laboratory information system or the hospital/facility registration system, OR obtain a waiver from the MCSS.
O Optional Laboratory does not need to send this information. It will be ignored if sent.
NA Not Applicable This data item is not applicable for cancer registries. B Backwards Compatible
Data item location in previous HL7 versions. Laboratory may submit the data in this location with approval from the MCSS.
Refer to Appendix B: HL7 Structure and Required Data items for complete standards and description of the requirements for submitting pathology reports as an HL7 message. Refer to Appendix C: NAACCR Standards for Cancer Registries, Volume V, appendix A for Pathology Laboratory Electronic Reporting for complete standards and description of the requirements for submitting pathology reports as an ascii file.
Version 5.0 8/1/2012 13
http://www.naaccr.org/filesystem/pdf/Standards_Volume_V_version_2.2_draftB_revised_February_2009.pdf All pathology reports must be submitted within 15 days of completion of the report, regardless of the availability of required data items. Laboratories should make every effort to obtain the required data items as they exist in their facility, but may not delay the submission due to missing data.
Version 5.0 8/1/2012 14
Use Case #1: Submission of pathology reports to the MCSS Notes: 07/07/04: Added to #1C: statement that an empty message should be transmitted when there are no reports to be submitted. This ensures that the MCSS receives a file every day. If a file is not sent for a particular day it means that a part of the system is not working.. The MCSS will verify its systems and then the lab will be contacted to verify that all of their systems are working.
#1A. Pathology Laboratory completes the MCSS E-path Reporting: Laboratory Assessment.2 Responsible Party: Laboratory and MCSS staff
1. Laboratory notifies the MCSS of interest in e-path reporting. 2. MCSS email documentation and Assessment to laboratory. 3. Laboratory completes Assessment and submits it to the MCSS.
4. The MCSS and laboratory review the Assessment and begin planning for e-path implementation.
#1B. Pathology Laboratory creates an HL7 message of pathology reports. Responsible Party: Pathology Laboratory
4. Use NAACCR HL7 Record Layout Structure for reporting pathology reports.3,4 5. Include all final (completed) pathology reports.
2 Appendix A: MCSS Electronic Pathology Reporting Assessment
3 Appendix B: MCSS Excerpted HL7 Segment Attributes from NAACCR Implementation Guide for Transmission of Laboratory-Based Reporting to Cancer Registries Using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol (November 2003)
4 NAACCR Implementation Guide for Transmission of Laboratory-Based Reporting to Cancer Registries Using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol (November 2003). Available via email upon request. [email protected]
Chapter
2
Version 5.0 8/1/2012 15
a. For laboratory not submitting non-MN residents’ pathology reports, a full HL7 message must be submitted that includes only the following data items:
i. the pathology report number; ii. specimen collections date; and iii. the statement “NON-MN RESIDENT in the first OBX segment
results segment [IS this the appropriate place?] 6. Include all report types.5 7. Include all required data items.6
a. If demographic data items are in the facility’s master patient index, they must be included in the pathology report submission record. Otherwise, demographic data items in the laboratory information system must be submitted.
8. Provide documentation on how late pathology reports will be identified and submitted to the MCSS.7
9. Provide documentation on method of reporting amended pathology reports (addenda, supplemental reports, etc.)8
10. Provide master list (or database table) of codes and definitions for each coded data item. [pipe-delimited ascii text file.]
11. Test File creation. a. All pathology reports are collected.
i. Create list of pathology report numbers in the laboratory for a specific time period (one day).
ii. Create HL7 file/message iii. Send both to the MCSS for comparison.
b. All required data items are complete. i. Create a test file/message of 5 reports for each pathology report
type. ii. Send to the MCSS for analysis.
12. Identify Laboratory Contact Person to coordinate routine submission activities and respond to error message notices, questions, etc. Include:
a. Contact for file structure and transmission issues; b. Contact for changes in report numbering systems, contents of the
pathology reports, required data items, etc.
5 Appendix A. MCSS Electronic Pathology Reporting Laboratory Assessment, Question 6.
6 Appendix B. MCSS Required Data items for Electronic Pathology Reporting (e-path).
7 Appendix A. MCSS Electronic Pathology Reporting Laboratory Assessment, Question 4.
8 Appendix A. MCSS Electronic Pathology Reporting Laboratory Assessment, Question 5.
Version 5.0 8/1/2012 16
#1C. HL7 Message is encrypted and sent to MDH. Responsible Party: Pathology Laboratory
1. [add: timeframe for reporting; frequency and lagtime] 2. [add: method of triggering file/message creation] 3. [add: method of encryption] 4. Create File/Message Submission Report
a. File/message creation date b. File/message transfer date c. Laboratory d. Number of records within the message. e. [add: other statistics?]
5. Send empty message if no reports are found. 6. [add: method of transmitting file to MDH.] 7. Transmit File/message and Submission Report to MDH PhinMS server. 8. [MDH] Send email to laboratory, MCSS-IT, FS representative, DM representative
regarding status of transfer. 9. Report errors
Notify laboratory, MDH IT, MCSS IT if number of records does not match with number submitted. Responsible party: __________________ Include:
a. Information in the laboratory Status Report. b. Number of records received c. List of pathology report numbers received.
Fairview: HL7: OBR.3.1: specnum_formatted.
Version 5.0 8/1/2012 17
Use Case #2: Transfer of files to the MCSS database and create load file.
#2A. Decript HL7 file #2B. Map HL7 data items to NAACCR pipe-delimited text structure.
1. Translate HL7 file/message to ascii pipe delimited file
a. Use NAACCR ascii Pipe Delimited Record Layout Structure for reporting pathology reports.9
b. Make hl7_err file and/or ascii_inc file. i. Notify “epr” if record(s) cannot be translated.
2. Clean up directories on computer systems.
9 See http://www.naaccr.org/filesystem/pdf/Standards_Volume_V_version_2.2_draftB_revised_February_2009.pdf
Chapter
3
Version 5.0 8/1/2012 18
Use Case #3: Processing of Electronic Pathology Reports at the MCSS #3A. Load ascii formatted file into the mcss database. Responsible Party: MCSS IT
1. Use MCSS standard module for loading ascii files into Sybase. 2. Load file into database10.
#3B. Standardize data to the MCSS standard.
1. See epr-scrubber. (not included)
#3C. Convert pathology report number to standard format.
1. Convert pathology report number to MCSS’ convert_path. a. use pathconvert: b. structure: xxxxccyynnnnnnnnnnnn.
#3D. Update monitoring/status tables
1. insert record into epr_pathnumbers. a. Create list of missing pathlogy numbers by report type for each laboratory.
i. Those missing for more than ____ days since the subsequent report number’s submission.
2. insert record into epr_stats table
10 Appendix E. MCSS E-Path Table Structures
Chapter
4
Version 5.0 8/1/2012 19
#3E. Identify resubmits and addenda. 1. Record results in epr_stats
#3F. Identify pathology reports that are potentially reportable to the MCSS.
1. Apply Optimized NAACCR Search Term List to new records.11 12 2. Insert reports that positively matched with the search term list into
mcss..epr_pend [db table]13. 3. Record results in mcss..epr_stats [db table]
.
#3G. Determine final reportability of pathology reports.
1. Compare all text against the MCSS Reportability List. 2. Delete reports that are not related to cancer from the database (with no back-up)
a. On a regular schedule (i.e. twice a year, all submitted pathology reports will be manually review to identify possible gaps in the Search Term List.
3. Code the pathology report using ICD-O-3. a. Primary Site b. Laterality c. Histology/ behavior code d. Grade e. Specimen type
4. Insert demographic, facility and coded medical information into the MCSS patient data tables (mcss..abstracts, mcss..abs_extra).
5. Add results to mcss..epr_stats [db table]. 6. Add results to mcss..epr_batch [db table].
11 MCSS optimized the NAACCR Search Term List so that only the root word of a reportable diagnosis is included. (Example: LEUKEMIA encompasses all of the lymphocytic, myeloid and other subtypes of leukemia.)
12 Appendix H. MCSS Optimized NAACCR Search Term List.
13 Appendix E. MCSS E-Path Table Structures
Version 5.0 8/1/2012 20
Version 5.0 8/1/2012 21
Appendix A: MCSS Electronic Pathology Reporting: Laboratory Assessment
1. Type and version of Laboratory Information System (LIS)
__________________________________________ version:__________
2. Method of submitting pathology reports electronically
____ HL7 ____ ascii pipe delimited file
3. Method of reporting Text information ____ All Text in one obx segment (or pipe delimited field) ____ Text reported in separate obx segments (or pipe delimited fields)
4. Method of identifying and submitting late reports
___________________________________________________________ ___________________________________________________________ ___________________________________________________________
5. Method of reporting amended/supplemental reports
___________________________________________________________ ___________________________________________________________ ___________________________________________________________
6. Method of identifying canceled pathology numbers (or re-assigned pathology numbers
___________________________________________________________
___________________________________________________________
Version 5.0 8/1/2012 22
7. Laboratory Pathology Report Types
Prefix Report Type: Definition/Comments Recycle numbers annually?
Comments:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Version 5.0 8/1/2012 23
Laboratory Assessment of Data Items (Required data items are in bold; other data items must be submitted if they are available at the facility.) Data Item Available
in Lab database
Available in Hosp. database
Comments; Alternative data items
Pathology Facility ID Number
Laboratory Name Street City State Zip Code Telephone Patient Name Last Name First Name Middle Name Patient Address Street City/Town State Zip Code Date of Birth (or path-age at specimen)
Social Security Number Sex Medical Record Number Path-Slide/Pathology Report Number
Path Ordering Client/Physician (Attending)
Last Name First Name Middle Name Street City State Zip Code Work Facility ID Number
Version 5.0 8/1/2012 24
Data Item Available in Lab database
Available in Hosp. database
Comments; Alternative data items
Pathologist Date of Specimen Collection
Path-Text-Diagnosis Clinical History Nature of Specimen Gross Pathology Microscopic Pathology
Final Diagnosis MCSS Incidence Status*
Comment Section Supplemental Reports and/or Addenda
Staging Parameters Date Transmitted * Pathologist’s determination of whether this is a newly diagnosed cancer (within 2 months) or prevalent (including a dxdate of when the cancers was diagnosed.)
Version 5.0 8/1/2012 25
Appendix B: HL7 Structure for E-path Reporting
The MCSS requires that data items marked as R or RE be submitted, if available in the facility. This includes data items available in the medical record and billing systems as well as the laboratory information system. A pathology report must be submitted when it has been marked complete, even if one or more required data items are not available. The required data item location is left empty if the data is not available. Optional data items may be filled at the decision of the laboratory creating the message. The MCSS will protect all data item submitted with the same level of protection as the required information. The following Segment Attribute Tables are excerpted directly from the NAACCR Implementation Guide for Transmission of Laboratory-Based Reporting to Cancer Registries using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol (Draft Nov. 2003. The only modifications are:
• Modifying the OPT column to be the requirements for the MCSS; and • Placing the tables in a different order to match the standard hl7 message
transmission format.
Version 5.0 8/1/2012 26
HL7 batch file structure and Segment Definitions A batch of HL7 messages may be sent online using a common file transfer protocol or offline via tape or diskette. If needed, a group of batches may be sent using the file header and trailer segments. The FHS and FTS are optional and need not be sent if the transaction is one batch of records. The file/batch syntax follows:
[FHS] (file header segment) { [BHS] (batch header segment) { [MSH (zero or more HL7 messages) PID OBR .... ] } [BTS] (batch trailer segment) } [FTS] (file trailer segment)
File Header (FHS) Segment The FHS segment is used to head a file (group of batches). Ideally, a single sending facility, for instance a regional laboratory for a hospital consortium, could send a group of batches of reportable findings from separate laboratories within the consortium. In this setting, each separate BHS would have a different CLIA identifier. The FHS would have a different CLIA number as well, or would have the same CLIA number as the one batch that was performed at the sending facility. This complexity of message processing is not common yet, either at laboratories or public health agencies. The description of batch reporting in this guide demonstrates reporting from a single facility and thus the CLIA number is the same for MSH, BHS, and FHS. File Trailer (FTS) Used to define the end of a file. Batch Header (BHS) Segment Used to define the start of a batch. Batch Trailer (BTS) Segment Used to define the end of a batch. Message Header (MSH) Segment Used to define the intent, source, destination, and some specifics of the syntax of a message.
Version 5.0 8/1/2012 27
Patient Identification Segment (PID) Used by all applications as the primary means of communicating patient identification information. This segment contains permanent patient identifying and demographic information that, for the most part, is not likely to change frequently. Common Order Segment (ORC) Used to transmit fields that are common to all orders (all types of services that are requested). Observation Request Segment (OBR) The Observation Request (OBR) segment is used to transmit information specific to an order for a diagnostic study or observation, physical exam, or assessment. The OBR defines the attributes of a particular request for diagnostic services or clinical observations. For laboratory-based reporting, the OBR defines the attributes of the original request for laboratory testing. Essentially, the OBR describes a battery or panel of tests that is being requested or reported. The OBR is somewhat analogous to a generic lab slip that is filled out when physician requests a lab test. The individual test names and results for the panel of tests performed are reported in OBX segments, which are described below. As defined by the ORU syntax, there can be many OBX’s per OBR, and there can be many OBR’s per PID. Observation/Result Segment (OBX) The OBX segment is used to transmit a single observation or observation fragment. It represents the smallest indivisible unit of a report. Its principal mission is to carry information about observations in report messages. While OBR gives general information about the order for the test and ORC gives information on all services that are requested, the OBX segment gives the specific, individual tests performed (OBX-3) and the specific results for each test (OBX-5). Laboratory-based reporting to public health agencies focuses on OBX-3 and OBX-5 as the most informative elements of the message; thus, every effort should be made to make OBX-3 and OBX-5 as informative and unambiguous as possible. NOTES AND COMMENTS SEGMENT (NTE) The NTE segment is a common format for sending notes and comments. This optional, repeating segment may be inserted after any of the OBX segments in the ORU message. The NTE segment applies to the information in the segment that immediately precedes it, i.e., the observation reported in the preceding OBX segment. The NTE segment is not further defined by HL7.
Note: This segment is not routinely completed, however, if this section is used it should only include general comments, instructions, or results and not specific results.
Version 5.0 8/1/2012 28
Appendix C: ASCII Record Layout Structure The MCSS uses the record layout format developed by NAACCR for reporting pathology reports electronically in an ascii text file layout, found in the “NAACCR Standards for Cancer Registries, Volume V, Appendix B - Pathology Laboratory Electronic Reporting Pipe Delimited Format (Version 2.0; July 2009)” http://www.naaccr.org/filesystem/pdf/Standards_Volume_V_version_2.2_draftB_revised_February_2009.pdf
The NAACCR Standards document should be used only for the record layout format. All other portions of the document have been replaced with more updated information and should not be referenced or used. (Specifically, the data item requirements table in NAACCR Standards document is no longer current. Use the “MCSS Data Item Requirements for Electronic Pathology (epath) Reporting” (Table 1) already discussed in Chapter 1.
Version 5.0 8/1/2012 29
Appendix D: Data Item Mapping: HL7 NAACCR MCSS Table of data items required by the MCSS, identifying their location in an HL7 message, the NAACCR data item number and the location of the data item in the MCSS patient data tables.
HL7 position
Epath data
item #
Mapping software data item name
Data item
length
mcss..epath_pend fieldname
naaccr lay- out
num
n/a n/a n/a 1 recnum n/a Harcoded:
L 1 Record_Type 1 rectype 10
Hardcoded: 1
2 Path_Version_Number 6 layout_vers 7000
p 3 Path_Facility_ID_Number 25 submit_lab_num 7010 properties
file 4 Lab_Name 50 submit_lab_name 7020
"" 5 Lab_Street 25 submit_lab_street 7030 "" 6 Lab_City 20 submit_lab_city 7040 "" 7 Lab_State_or_Province 2 submit_lab_state 7050 "" 8 Lab_Zipcode_or_Postalcode 9 submit_lab_zipcode 7060 "" 9 Lab_Telephone_Number 10 submit_lab_telephone 7070
PID-5-1 10 Patient_Last_Name 25 lastname 2230 PID-5-2 11 Patient_First_Name 14 firstname 2240 PID-5-3 12 Patient_Middle_Name 14 middlename 2250
PID-11-1 13 Patient_Street 25 streetname 2330 PID-11-3 14 Patient_City 20 city 70 PID-11-4 15 Patient_State_or_Province 2 state 80 PID-11-5 16 Patient_Zipcode_or_Postalcode 9 zipcode 100
PID-11-13 17 Patient_Telephone_Number 10 telephone 2360 PID-7 18 Patient_Date_of_Birth 8 date_of_birth 240 ???? *19 Patient_Age_at_Specimen 10 pathage 7080
PID-3 20 Patient_Social_Security_Number 9 ssn 2320 PID-8 21 Patient_Sex 1 sex 220 PID-3 22 Patient_Medical_Record_Number 11 medrecnum 2300
OBR-3 23 Pathology_or_Slide_Report_Number 20 pathnumber 7090 OBR-16-1 24 Path_Order_Person_License 8 doc1num 7100 OBR-16-2 25 Path_Order_Person_Last_Name 25 doc1lname 7110 OBR-16-4 26 Path_Order_Person_First_Name 14 doc1fname 7120 OBR-16-5 27 Path_Order_Person_Middle_Name 14 doc1mname 7130 0RC-24-1 28 Path_Order_Person_Street 25 doc1_street 7140 ORC-24-3 29 Path_Order_Person_City 20 doc1_city 7150 ORC-24-4 30 Path_Order_Person_State_or_Province 2 doc1_state 7160 ORC-24-5 31 Path_Order_Person_Zipcode_or_Postal
code 9 doc1_zipcode 7170
ORC-23 32 Path_Order_Person_Telephone_Number
10 doc1_telephone 7180
ORC-21-3 33 Path_Work_Facility_ID_Number 25 trtfacility_license 7190 ORC-21-1 34 Path_Work_Facility_Name 50 trtfacility_name 7200 ORC-22-1 35 Path_Work_Facility_Street 25 trtfacility_streetadd 7210 ORC-22-3 36 Path_Work_Facility_City 20 trtfacility_city 7220
Version 5.0 8/1/2012 30
0RC-23-4 37 Path_Work_Facility_State_or_Province 2 trtfacility_state 7230 ORC-22-5 38 Path_Work_Facility_Zipcode_or_Postalc
ode 9 trtfacility_zipcode 7240
ORC-23 39 Path_Work_Facility_Telephone_Number 10 trtfacility_telphone 7250 OBR-32 40 Path_Reporting_
Pathologist_Last_Name 25 pathmd_lname 7260
OBR-32 41 Path_Reporting_ Pathologist_First_Name
14 pathmd_firstname 7270
OBR-32 42 Path_Reporting_ Pathologist_Middle_Name
14 pathmd_middlename 7280
OBR-32 43 Path_Reporting_ Pathologist_Suffix 3 pathmd_suffix 7290 OBR-32 44 Path_Pathologist_License_Number 8 pathmd_license 7300 0BR-32 45 Path_Pathologist_State_Licensor 2 pathmd_state_license 7310 OBR-7 46 Path_Date_of_Specimen_Collection 8 specdate 7320
BOX-11 47 Path_Status_Individual_Result 1 path_report_status 7330 OBX-CE-5 48 Path_SNOMED_Codes 18 snomed 7340
???? *49 Path_SNOMED_Version_Control 5 snomed_version 7350 "" 50 Path_ICD_Code 10 icd_code 7360 "" 51 Path_ICD_Revision_Number_Code 5 icd_version 7370 "" 52 Path_CPT_Code 5 cpt_code 7380 "" 53 Path_CPT_Code_Version 5 cpt_version 7390
OBX-5 54 Path_Text_Diagnosis 44800 path_text_diagnosis 7400 "" 55 Path_Clinical_History 1000 path_text_clin_history 7410 "" 56 Path_Nature_of_Specimen 1000 path_nature_of_specimen 7420 "" 57 Path_Gross_Pathology 1000 path_gross 7430 "" 58 Path_Microscopic_Pathology 1000 path_micro 7440 "" 59 Path_Final_Diagnosis 1000 path_final_dx 7450 "" 60 Path_Comment_Section 1000 path_comments 7460 "" 61 Path_Supplemental_Reports 1000 path_supplemental 7470 "" 62 Path_Staging_Parameters 1000 path_staging 2600
MSH-7 63 Date_Transmitted 8 date_transmitted 2110 OBR-24 64 Path_Report_Type 2 path_report_type 7480
n/a n/a n/a 1 supplemental n/a n/a n/a n/a 20 convert_path n/a n/a n/a n/a 1 coder1 n/a n/a n/a n/a 1 coder2 n/a
Version 5.0 8/1/2012 31
Appendix E: Table Structures epr table list
mcss.epr.epr_data # raw epr data (ascii file structure)
mcss.epr.epr_wrk # data extract and transform (epr_pend structure)
mcss.epr.epr_recnum # last used epr recnum
mcss.epr.epr_batchnum # last used epr batchnum
mcss.epr.epr_testing_lab_locations # lookup table for MCSS pathlab
mcss.epr.epr_trtfacility_clients # lookup table for MCSS trtfacility
mcss.epr.epr_pend # stl reportable epr: awaiting DM coding
mcss.epr.epr_first_code # DM first code epr results
mcss.epr.epr_second_code # DM second code epr results
mcss.epr.epr_batch_YYYY # epr batch info for current year
mcss.epr.epr_stats_YYYY # epr statistics for current year
mcss.epr.epr_batch_archive # epr batch info archive for all previous years
mcss.epr.epr_stats_archive # epr statistics archive for all previous years
mcss.epr.epr_pathnumbers # all epr submitted pathnumbers
mcss.epr.epr_nr # MCSS NON-reportable epr (stl reportable)
mcss.dbo.abs_epr # MCSS reportable epr (stl reportable)
Version 5.0 8/1/2012 32
Version 5.0 8/1/2012 33
Mcss.epr.epr_batch_2004 One record per batch of pathology reports.
Data Item Data Type Comment batch Int Sequential number for each file submitted,
regardless of laboratory create_date_lab Datetime Date Laboratory created the file pathlab Int MCSS pathology laboratory code filename_lab Text Name given to the file by the pathlab filename_mcss Text Name given to the file by mcss process_date_mcss Datetime Date mcss began processing file Num_rec_submitted Int Number of records in the file num_hl7_records Int Number of records found by the mcss hl7
reader num_hl7_bad Int Number of records that do not meet mcss hl7
structure num_hl7_good Int Number of records that meet the mcss hl7
structure num_ascii_incomplete Int Number of records that have incomplete
information in the record num_missing_path Int Number missing pathnumber num_missing_text Int Number missing text num_ascii_good begin_recnum Int First of sequential record control numbers
assigned to path reports in the batch end_recnum Int Last of sequential record control numbers
assigned to path reports in the batch num_resubmits Int Number of resubmitted reports num_positive Int Number of reports that positively matched with
a term on the Search Term List num_negative Int Number of reports that did not match with any
term on the Search Term List final_reportable Int Final number of reportable pathology reports
in the batch coder1 Int MCSS abstractor code for the person first
processing the batch of reports coder2 Int MCSS abstractor code for the person second
processing the batch of reports mcss.epr.epr_stats_2004 One record for each pathology report submitted as a complete, good ascii record. Data Item Data Type Comment batch int recnum int Sequential record control number assigned
Version 5.0 8/1/2012 34
to each path report date_created Datetime Date Laboratory created the file pathlab Int MCSS pathology laboratory code convert_path Varchar(20) MCSS’ Converted pathology report number
assigned to the path report pathnumber Varchar(15) Pathology report number assigned by the
laboratory stl_reportable Char(1) search term list (stl) decision of whether
report is reportable (Y) or not-reportable (N) staff_reportable Char(1) Mcss staff decision of whether report is
reportable (Y) or not-reportable (N) reviewed_by Int Abstracter/region code coder1 Int Abstracter code for first coder coder2 Int Abstracter code for second coder dm_consult Char(1) Date a pathology report assigned to pending supplemental Char(1) Whether report is a supplemental report completed Datetime Date final resolution of pathology report Supp_lognumber Int Sequential number assigned to an abstract
inserted into the main database (mcss..abstracts)
mcss.epr.epr_pathnumbers One record per pathnumber submitted for each laboratory. Uses the MCSS converted pathology report number so that numbering is standardized. Data Item Data Type Comment pathlab Int MCSS pathology laboratory code convert_path Varchar(2) Converted pathology report number tabledate Datetime Date record inserted into the table
Version 5.0 8/1/2012 35
mcss.epr.epr_pend One record per pathnumber submitted for each laboratory. Data record from laboratory that will be reviewed for reportability and coded (if reportable). recnum int rectype varchar 1 layout_vers varchar 6 submit_lab_num int submit_lab_name varchar 50 submit_lab_street varchar 25 submit_lab_city varchar 20 submit_lab_state varchar 2 submit_lab_zipcode varchar 9 submit_lab_telephone varchar 10 lastname varchar 25 firstname varchar 14 middlename varchar 14 streetname varchar 25 city varchar 20 state varchar 2 zipcode varchar 9 county varchar 3 telephone varchar 10 date_of_birth varchar 8 pathage varchar 10 race varchar 1 ssn varchar 9 sex varchar 1 medrecnum varchar 11 doc1num varchar 6 doc1lname varchar 15 doc1fname varchar 10 doc1mname varchar 1 doc1_street varchar 25 doc1_city varchar 20 doc1_state varchar 2 doc1_zipcode varchar 9 doc1_telephone varchar 10 doc2num varchar 6 doc2lname varchar 15 doc2fname varchar 10 doc2mname varchar 1 trtfacility int trtfacility_license varchar 25 trtfacility_name varchar 50
Version 5.0 8/1/2012 36
trtfacility_streetadd varchar 25 trtfacility_city varchar 20 trtfacility_state varchar 2 trtfacility_zipcode varchar 9 trtfacility_telephone varchar 10 pathlab int 4 pathnumber varchar 20 convert_path varchar 20 specdate varchar 8 pathmd_lname varchar 25 pathmd_firstname varchar 14 pathmd_middlename varchar 14 pathmd_suffix varchar 3 pathmd_license varchar 8 pathmd_state_license varchar 6 path_report_status varchar 1 snomed varchar 18 snomed_version varchar 5 icd_code varchar 10 icd_version varchar 5 cpt_code varchar 5 cpt_version varchar 5 path_text_diagnosis text path_text_clin_history text path_nature_of_specimen text path_gross text path_micro text path_final_dx text path_comments text path_supplemental text path_staging text date_transmitted varchar 8 path_report_type varchar 1 Supplemental varchar 1 tabledate datetime
Version 5.0 8/1/2012 37
mcss.epr.epr_first_code One record per pathnumber submitted for each laboratory that has been coded by a Data Management Representative. Record remains in this table until the full batch of reports has been first and second coded and the records dispersed to either mcss..rawtable or mcss..epr_nr. recnum int primarynum int coder varchar (3) decision char (1) nr_code int trtfacility int pathlab int specdate varchar (8) pathnumber varchar (15) sex varchar (1) site varchar (4) laterality varchar (1) histo varchar (5) grade varchar (2) spectype varchar (2) incident varchar (1) dxdate varchar (8) consultstatus varchar (1) reviewlab int abs_notes varchar (255) coder_notes varchar (255) tabledate datetime
Version 5.0 8/1/2012 38
mcss.epr.epr_nr One record per pathnumber submitted that has been determined to be nonreportable but useful for administrative functions (ie. Case ascertainment, residency, diagnosis date, etc.) recnum int pathlab int lastname varchar (15) firstname varchar (10) pathnumber varchar (12) dob char (8) sex char (1) medrecnum varchar (12) accession_date char (8) blurb text nr_code int nr_rationale varchar (72) tabledate datetime epr log for each file Data Item Program + Version Date MCSS Filename Date Lab Created File Error Message: File not Found Number of Records Submitted Number of HL7 Records Number of bad HL7 Records Number of good HL7 Records Number of bad ASCII Records Number of Incomplete ASCII Records Number of good ASCII Records Number Missing Pathnumber Number Missing Treatment Facility Number Missing Text Num_missing_lastname Debug/Notification Messages Error Messages
Version 5.0 8/1/2012 39
Appendix F: Email Messages
Header for ALL email messages:
Date: Laboratoy Laboratory File Creation Date Laboratory File Name MCSS File Name To: fs-rep, nancy, chris, mila, sally, brenda (and LAB-IT when noted below)
Bad HL7 Record (a non-standard hl7 record is received.)
To: add: LAB-IT
“The following pathology report numbers could not be translated due to an unexpected error in reading the HL7 message. Please review your original file to determine error in HL7 structure.
Contact Ashley Harvieux: 651-201-5191 [email protected] with questions and resolution of problem records.
Thank you very much.” [List of record numbers + pathology report numbers, if possible ]
Incomplete ASCII Record (critical data item(s) missing from a record.)
To: add: LAB-IT
“The following pathology report numbers are rejected due to missing critical data items (pathology report number, treatment facility, text, patient name). Please review the review and re-submit a complete pathology report record.
Contact Ashley Harvieux: 651-201-5191 [email protected] with questions and resolution of problem records.
Thank you very much.” [List of record numbers + critical data item that was missing]
Version 5.0 8/1/2012 40
Appendix G: File structure for epr files
Version 5.0 8/1/2012 41
Appendix H: Ecode software Ecode is used to review, first and second code pathology reports.
Table 1: Ecode action first to second code
1st Code
Action 2nd Code
Action
“1st code marked as delete” D Delete record [no error messages, no discrepancies]
D “1st code marked as delete” N Move the record to epr_nr. [No error messages, no discrepancies.]
D “1st code marked as delete” C Send Record To DM Consult
D “1st code marked as delete” R Insert record into rawtable Move record from epr_pend to abs_epr Add to discrepancies list
N “1st code marked as NR” N Move record to epr_nr [use the nr code from the 2nd code] [no error messages, no discrepancies.]
N “1st code marked as NR” D Error msg: “You can’t delete a record that the 1st code marked as NR. Use NR or DM Consult or Code it if it is reportable.”
N “1st code marked as NR” C Send record to DM Consult
N “1st code marked as NR” R Insert record into rawtable Move record from epr_pend to abs_epr Add to discrepancies list
R Fields are coded D Error msg: You can’t delete a record that the 1st coder made Reportable. Send to DM Consult or Code it if it is reportable.”
R Fields are coded N Error msg: You can’t make a record NR that the 1st coder made reportable. Send to DM Consult or Code it if it is reportable.”
R Fields are coded C Record sent through DM Consult process
R Fields are coded R Insert record into rawtable Move record from epr_pend to abs_epr Check for discrepancies between 1st code and 2nd code
Version 5.0 8/1/2012 42
1st Code
Action 2nd Code
Action
D “1st code marked as delete”
D Delete record [no error messages, no discrepancies]
N “1st code marked as NR” D Error msg: “You can’t delete a record that the 1st code marked as NR. Use NR or DM Consult or Code it if it is reportable.”
R Fields are coded D Error msg: You can’t delete a record that the 1st coder made Reportable. Send to DM Consult or Code it if it is reportable.”
C Can’t mark C as first coder
D
D “1st code marked as delete”
N Move the record to epr_nr. [No error messages, no discrepancies.]
N “1st code marked as NR” N Move record to epr_nr [use the nr code from the 2nd code] [no error messages, no discrepancies.]
R Fields are coded N Error msg: You can’t make a record NR that the 1st coder made reportable. Send to DM Consult or Code it if it is reportable.”
C Can’t mark C as first coder
N
D “1st code marked as delete”
R Insert record into rawtable Move record from epr_pend to abs_epr Add to discrepancies list
N “1st code marked as NR” R Insert record into rawtable Move record from epr_pend to abs_epr Add to discrepancies list
R Fields are coded R Insert record into rawtable Move record from epr_pend to abs_epr Check for discrepancies between 1st code and 2nd code
C Can’t mark C as first coder
R
D “1st code marked as delete”
C Send Record To DM Consult
N “1st code marked as NR” C Send record to DM Consult
R Fields are coded C Send record DM Consult process
Version 5.0 8/1/2012 43