Pathology – GP Order Comms HL7 UK Technical Committee 9 th December 2008 Paul Richardson.

Pathology – GP Order Comms

HL7 UK Technical Committee9th December 2008

Paul Richardson

Project Background

Under the auspices of the Modernising Pathology Programme, the Department of Health (DH) is currently working in partnership with NHS Connecting for Health (NHS CFH) and other key stakeholders to improve IT connectivity between GP practices and pathology laboratories.

Pathology Modernisation Agenda• Carter Report

– Lord Carter of Coles was appointed to lead an Independent Review of NHS pathology services in September 2005. The Report of the Review of NHS Pathology Services in England was first published in August 2006.

– A key recommendation is that within pathology there should be end-to-end IT connectivity and national availability of order communications and decision support, based on an agreed data set.

– Final report publication due ‘sometime’ 2008

Where are we now?

• PMIP - Pathology Messaging Implementation Project.

• Pathology messaging standards for information content, structure, management and security of electronic pathology report messaging between laboratories and

GPs • Well established and in place since the late 1990’s• Messaging standard originally delivered by X400 and

DTS since 2003• Highly successful project which has achieved nearly

universal take-up.

Very high volume business

Around 700 million tests conducted in England last year!

Around 40% of which were ordered by GPs.

PMIP – Limitations

• Offers only a limited electronic reporting service– Only Clinical Biochemistry & Haematology receive fully

structured report messages

• Does not provide electronic requesting

• Uses an EDI legacy messaging standard which is not understood by current strategic applications such as the NHS Care Records Service

• Critically, relies on legacy DTS communications infrastructure which is due to shut down in mid 2010

Benefits

• Patients – improved reliability of service – through fewer

inappropriate tests, fewer lost results, fewer duplicated tests and less chance of the wrong samples being taken;

– faster results – especially those that could not previously be sent electronically;

– secure requests and results - knowing that personal information can only be seen on a ‘need to know’ basis by healthcare professionals

– improved patient choice – through more flexible phlebotomy services.

Benefits

• Pathology Laboratory Services– Improved data quality– reduction in the repetitive data entry of patient

demographics and sample details;– faster and more efficient specimen reception as a

result of improved workload planning and receipt of complete and accurate information;

– improved resource and manpower management as a result of better workload planning;

– overall reduction in sample turnaround times with faster results reporting;

– fewer enquiries and phone calls to the laboratory from GP practices;

– fewer sample labeling errors.

Benefits

• GP Practices– help inform the practice about the appropriateness

of tests and the correct specimens to take; – avoid handwriting requests and enable more

results to be received and filed electronically;– assure automated filing of results into the patient

records;– receive more results electronically including all

pathology disciplines;– facilitate the introduction of decision support which

checks the relevance of the request, resulting in fewer requests being rejected;

– help ensure results are available for when patient appointments are made;

– printing of specimen labels.

Phase 1“Establishing interoperability”

• Pathology test requesting for all disciplines using HL7v3 messaging

• Pathology test reporting • Tests selected from the National Laboratory Medicine

catalogue• Sending sample information to the lab following

phlebotomy• Samples and requests must be marked with a common

request identifier• Reporting on outstanding tests• Support for screening programme status codes• Support for Confidential tests• Results of tests ordered by other parties copied to the GP

system

Phase 2

This phase introduces the following key functional features:

• Lab-to-lab test referrals• Test Request Templates as an aid to efficiency

and standardisation for GPs• Some further coding in both requests and

reports, including the coding of microbiology results

• Support for more unusual sampling scenarios• Requesting tests directly from the HPA

Phase 3

This phase introduces the following key functional features:• Choice of laboratory for GPs• Sending reports to copy recipients• Many more coded items in the request, including the

reason for the test, and the supporting information• Coding of results in the report for all disciplines, including

mandatory coding for histology• Cancellation of a test request by the requester• Test status checks• Clinician sealing• Recording ‘refusals to seal’

Message interactions

Message Interaction Name Interaction ID MiM Version

Order Fulfilment Request w/ RR POLB_IN020001UK01 7.2.02

Order Confirm Response POLB_IN020002UK01 7.2.02

Result In Progress w/RR POLB_IN020005UK01 7.2.02

Result Complete w/RR POLB_IN020006UK01 7.2.02

Application Acknowledgement MCCI_IN010000UK13 7.2.02

• Phase 2• Sample tracking

• messages currently under discussion with HL7 xxx

• Phase 1• Sub set of the HL7 Pathology ballot pack• A number of message types in full set redundant due to technical implications of the spine messaging ebXML and HL7 acknowledgements.

HAM

Std msg queue

Retry to std contract properties then:

Order message A

ebXML ackebXML ack

Order message A

ebXML ackebXML ack

MCCI..13 HL7 ack message AMCCI..13 HL7 ack to message A

message validation

check

Order Confirmation / rejection – msg B

ebXML ackebXML ack

ebXML ackebXML ack

MCCI..13 HL7 ack message BMCCI..13 HL7 ack to message B

Order Confirmation / rejection – msg B

Process order and store on inbound queue

confirm / reject

message initiation

GP app initiates order

message.

GP app to update order id

Message validation

check

Create and send message

Sample received and matched to

order

Order placement and confirmation

LabApplication / MHS

GPApplication / MHS

TMS

GPApplication / MHS

LabApplication / MHS

HAM

Std msg queue

Retry to std contract properties then:

Slow retry for x hours

Send result

message

ebXML ack ebXML ack

ebXML ack ebXML ack

MCCI..13 HL7 ack to message ZMCCI..13 HL7 ack to message Z

report complete

and initiates

message to GP system

Result msg Z Result msg Z

validate HL7

message and send

MCCI response

Store result report

Results

Some technical challenges

• Service discovery– Common point to point messaging issue– Directory of service for point to point services

• Choosing the appropriate interaction style

• TMS message reliability services (HUM / HAM)

• SNOMED-CT coding

Pathology Catalogue

The Pathology Catalogue consists of two components:– National Laboratory Medicine Catalogue

• Nationally agreed content• Coded reference file of tests

– Lab specific changes• The lab “Handbook”• Each lab can add their own additional attributes• Each lab cuts down the national list to those tests

provided• Can include rich content, including images, data

tables, documents, etc.

Pathology Catalogue – Content

National Catalogue

Local Lab Catalogue & Handbook

All

nat

ion

al

test

s

Basic coded reference content

Nationally agreed

Lo

cal

sub

set

of

test

s

Rich decision support contentLocally agreed

Pathology Catalogue – Hosting

National Catalogue

Local Lab Catalogue & Handbook

Hosted nationally by TRUD

Hosted nationally by new web service, with defined interface

NMAS

There is currently a test service that assures the existing PMIP EDIFACT messages, the National Messages Assurance Service (NMAS)

NMAS currently has 3 purposes:1.Provide connection confirmations between

services2.Message compliance checks3.Clinical governance reporting

NMAS Replacement Requirements

A replacement for NMAS will be needed:- to perform message compliance testing during

product and deployment testing- to perform ongoing message compliance once

live- to perform ongoing clinical governance reporting

NMAS Replacement Solution

The replacement solution involves:- Using the OMVT2 toolset to run content

compliance testing on messages- Using the “Spine in a box” to perform structural

and message interaction testing- Ongoing compliance and clinical governance

testing to use similar scripts to OMVT2, but only run on 1-in-n messages

NMAS Future

New NMAS solution could be expanded to support other programmes in an ongoing message assurance capability

Message refinements

The CfH pathology domain messages are a significant refinement of the .org model, both in terms of:• the use of interactions• message constraints

The design focus was to simplify in order to support GP ordering with some consideration for lab to lab ordering.

Message interactions

We’ve adopted a reduced set of interactions, e.g. no status check interaction

We’ve simplified our approach to replacing reports. This can only be performed at a ‘whole report’ level.

A difficult decision related to how to support sending information relating to the sample collection process.• We decided to send the request message again, with no change from the original order except for the addition of the sample collection information

Message design

•The usual UK modifications– we have just relaxed the restrictions on the use of the NHS number

– Use of CfH vocabs

– SNOMED-CT

•A new report focal act was introduced – LaboratoryReport•The CMET carrying the specimen related information was significantly simplified resulting in ‘SpecimenLite’:

– It is designed to be used for general Laboratory requests and reports without the overhead of the requirements of Automation or Specimen Tracking. It is constrained for use with Human subjects and excludes environmental, non-human and manufactured specimens.

•Numerous other changes•All valid constraints

Message documentation

•Very substantially revised tabular text•Many XML examples – chosen to demonstrate the use of all significant message feature•Using the IM page to specify message patterns and construction principles for requests and reports•About to embark on a refresh of some of the earlier business analysis artefacts

CfH Comms and Messaging have said that because of the attention to detail that we’ve applied to the documentation and the prototyping and consultation process, they believe that the Pathology domain will be the easiest to support. They typically are used to floods of queries from suppliers asking for clarification and guidance.

Requirements development processBy “requirements” I mean functional and non-functional requirements

and the MIM.

1. Write initial set (publish in MIM as draft)

2. Consult internally

3. Refine

4. Consult selected vendors and users

5. Refine

6. Develop example XML messages

7. Develop assurance tools and scripts

8. Develop prototype with selected vendors and users

9. Assure prototype messages

10. Refine requirements and specifications

11. Publish as normative

Future uses of the message set

The GP order comms project establishes a set of standards for pathology order comms in England.

The lab will be able to accept requests from many other settings such as prisons, care homes, community care and the acute sector.

Population screening services could also use the message set, e.g.• Newborn blood spot screening results sent from screening labs to

child health systems• Bowel cancer results sent from the screening labs to GP systems