Private Pathology and Diagnostic Imaging integration with ... · 6/15/2017 · • Once a document (Pathology or Diagnostic Imaging report) is uploaded it can later be removed •

www.digitalhealth.gov.au

Private Pathology and Diagnostic Imaging integration with My Health Record

Christian Holmes & Angus Millar

Digital Health Solution Architects

Australian Digital Health Agency

15 June 2017

www.digitalhealth.gov.au2

Patient Consent

Healthcare Identifiers

My Health Record Connectivity

Pathology and Diagnostic Imaging Reports

Integration Tools & Libraries

My Health Record Viewing


Patient Consent


Patient consent


My Health Record uploading

Diagnostic Report CDA/PDF

Healthcare Identifier Service

My Health Record System


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• The My Health Record operates on the principle of standing consent.

• Healthcare providers do not need to explicitly obtain permission from the patient before accessing or uploading information to their My Health Record.

• However controls need to be in place to prevent information (such as a diagnostics report) being sent to the My Health Record if the patient tells their provider that they don’t want it sent.

Patient Consent


Patient Consent

There are only two consent states:

• Patient consent not withdrawn (default)

• Patient consent withdrawn

The diagnostics industry have agreed that consent is applied on a per request / episode basis, it is not at the order item level.


Patient Consent

• A “withdrawal of consent” question will begin to appear on printed request forms, and where applicable, on the electronic request.

• The agreed question to appear on printed request forms is:‘Do not send reports to My Health Record [tick box]’

(default is unticked)

• We are currently working with the diagnostics sector to agree where this should appear on the paper forms.


Patient Consent

Best Practice (beta version under development)Pathology ordering screen

This description will be changed in the final release to:

‘[tick box] Do not send reports to My Health Record’


Patient Consent

In electronic orders, the status takes the form of:

‘Patient consent withdrawn’

Or

‘Patient consent not withdrawn’

The full Health Level Seven (HL7) V2 technical specification for the consent messaging can be found in the documents:

IndicationOfConsent_HL7v2Implemenation_dv011 20161229.pdf

IndicationOfConsent_MessageScenarios_dv007 20170117.pdf


Patient Consent

GP Diagnostic Order Request

Do not send reports to My Health Record [ ]

FBC

LFT

BSL

HL7 V2 ORM Electronic Order

FBC: Patient consent withdrawn

LFT: Patient consent withdrawn

BSL: Patient consent withdrawn

LIS / RIS Diagnostic Service system


FBC

LFT

BSL

Current Implementations

GP Diagnostic Order Request


FBC

LFT

BSL

HL7 V2 ORM Electronic Order

FBC: Patient consent not withdrawn

LFT: Patient consent not withdrawn

BSL: Patient consent not withdrawn

LIS / RIS Diagnostic Service system


FBC

LFT

BSL

Electronic order consent scenarios


Document Consent

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Key elements specified in an electronic order for My Health Record:

• My Health Record document withdrawal of consent

• Patient Demographics (family, given, middle name, date of birth)

• Patients Individual Healthcare Identifier (IHI)

• My Health record disclosure indicator

• Requesting providers Healthcare Provider Identifier for Individuals (HPI-I)

(Note: elements will be supplied by the ordering system where known.)

Patient Consent


Document Consent

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• Consent can be withdrawn at any time prior to document upload.

• Once a document is uploaded, if a patient later informs that they wish to change their consent to withdrawn, providers are not obliged to remove the document.

• Patients are able to remove the document from their own record via the consumer portal or may contact the consumer hotline for assistance: Help line: 1800 723 471

• Providers are not obliged to upload a document; if in doubt regarding consent, then do not upload.

• Independent of the patients consent, providers can choose to not upload for other reasons relating to clinical or mental health concerns, sexual health, etc.

Patient Consent




Patient consent







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Individual Healthcare Identifier (IHI)


Healthcare Provider Identifier for Individuals (HPI-I)

Healthcare Provider Identifier for Organisations (HPI-O)


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• The Healthcare Identifiers (HI) Service is operated by the Department of Human Services (Human Services)

• Authentication to the HI Service is via a HI certificate which is identical to the Medicare online certificates used for billing. You are able to link both services under the same certificate or keep them separate.

• My Health Record connectivity uses a separate National Authentication Service for Health (NASH) certificate

• The HI service provides a set of web services for managing IHIs, HPI-Is and HPI-Os

Healthcare Identifiers (HI) Service


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Individual Healthcare Identifiers (IHI)


• The IHI is a consumer / patient identifier

• It is a nationally and globally unique identifier

• Every Australian with a Medicare number has been assigned an IHI

• The Healthcare Identifiers (HI) Service, provides web services to search for and validate IHIs

• Pathology and Diagnostic Imaging service providers are not required to validate IHIs, only if the that IHI is received in an electronic request and the Pathology or Diagnostic Imaging provider does not have HI Service connectivity


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Healthcare Provider Identifier for Individuals (HPI-I)

• The HPI-I is a healthcare provider identifier e.g. Doctor


• Healthcare providers registered with Australian Health Practitioner

Regulation Agency (AHPRA) are automatically assigned a HPI–I

• Providers not registered with AHPRA can apply for a HPI–I from the HI

Service operator


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Healthcare Provider Identifier for Individual (HPI-I)

• For Pathology and Diagnostic Imaging Report Clinical Document Architecture

(CDA) documents, it is mandatory that the author’s HPI-I is provided

• The author in this context maybe the chief or department head reporting

Radiologist / Pathologist

• In exceptional circumstances a temporary HPI-I exception can be applied for

and a modified CDA template package implemented


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• Organisations that provide healthcare services and employ one or more healthcare providers can apply for an HPI-O from the HI Service.


• My Health Record uploading systems must upload under the context of a HPI-O

• NASH certificates can be issued and linked to a HPI-O and are required for My Health Record connectivity

• Organisations can create a seed and networked HPI-O structure

Healthcare Provider Identifier for Organisations (HPI-O)


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HPI-O Network structure

Seed HPI-O

Networked HPI-O Networked HPI-O Networked HPI-O

What is a HPI-O Network structure?

• Each network node is assigned a HPI-O• The seed node is the root parent, this may be the overarching organisation e.g. (Acme Healthcare)• Each child node is an organisation associated under the seed node e.g. (Acme NSW, Acme VIC, Acme QLD)• You may even have more networked child nodes under child nodes, although this is not common• Some organisations may choose to only have a seed, or perhaps a seed and one networked node


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HPI-O Network structure

Seed HPI-O

Networked HPI-O Networked HPI-O Networked HPI-O

Why have HPI-O Network structure?

• When you upload to the My Health Record each upload will be recorded and visibly seen as being uploaded by one and only one HPI-O

• It allows your organisation to maintain its commercial sub branding • The patient My Health Record access controls are applied against HPI-Os, having a structure allows the

patient to block one while allowing access to another• As commercial sub brands are bought and sold between larger organisations they can be easily disassociated

and reassociated to a new seed organisation without the need for a new HPI-O


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HPI-O and certificates

Seed HPI-O

Networked HPIO

Networked HPIO

Networked HPIO

• The HPI-O is only an identifier and it must be linked to a certificate to allow that HPI-O’s system to authenticate and access the My Health Record

• Connecting systems authenticate with the My Health Record using a NASH certificate

• The HI Service requires a HI Service (Medicare) certificate

• Both certificates are linked to HPI-Os, you can have both linked to a single HPI-O

• You only need a single HI Service (Medicare) certificate, recommended at the seed HPI-O level

• Depending on the organisational structure you may require one or many NASH certificates


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HPI-O Network structure with linked certificates

Seed HPI-O

Networked HPI-O Networked HPI-O Networked HP-IO

HI Service Certificate

My Health Record NASH Certificate

HI Service


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Patient consent







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• Prior to upload, the connecting system must have evidence that a record exists for the patient’s My Health Record you wish to upload to

• You can obtain this by either calling the My Health Record web service ‘Does PCEHR Exist’ or due to the disclosure of a record via the patient or third party system e.g. via an electronic order.

• Disclosure occurs by a patient informing you or a third party that they have a My Health Record. If you have obtained disclosure then you can attempt to upload without calling ‘Does PCEHR Exist’

• The ‘Does PCEHR Exist’ call will return False if a patient has chosen to hide their record via their access control settings in the My Health Record

• A ‘Does PCEHR Exist’ call returning False does not prevent systems from uploading if they have obtained disclosure

• Record access controls prevent systems from viewing a patient’s My Health Record unless a code is provided, this is independent from the ability to upload

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My Health Record ConnectivityMy Health Record discovery


• Once a system has discovered the existence of a patient’s My Health Record, either by ‘Does PCEHR Exist’ or via disclosure, the system can hold this information indefinitely.

• Should an upload fail this status should be set back to False until rediscovered

• System are advised to display the existence of a record to it’s users

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My Health Record Discovery


• The My Health Record system allows documents that have been previously uploaded to be replaced with a newer version through a supersede operation. This will occur when a diagnostics report has been uploaded and is subsequently amended or corrected.

• Systems will need to keep track of the document IDs that it has uploaded in order to later supersede that document e.g. (new Doc ID ‘50a1569a-190d-4fa6-bc72-6ecc02467ebd’ supersedes -> old doc ID ‘70c33b91-2490-44c2-9441-a52decd92c52’ )

• If consent is withdrawn after a document is uploaded, yet before a supersede is required, systems must either:

• Proceed with the supersede despite the current consent setting, or

• Remove the older document

The system MUST not leave orphaned or stale documents in the patient’s My Health Record

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My Health Record ConnectivitySuperseding Documents


• Once a document (Pathology or Diagnostic Imaging report) is uploaded it can later be removed

• All removals are logical removals, the document is still available for audit purposes although now inaccessible to most users

• By request, and under authorisation, the system operator can retrieve the entire audit in full

• There are two types of removals that provider systems can perform:

• Remove (Withdrawn):Used to remove a document with incorrect information, the document may be superseded with the correct information at a later point in time, or not

• Remove (Incorrect identity):Used to remove a document that has been inadvertently uploaded to an incorrect patient record. The document may not be reinstated or superseded

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My Health Record ConnectivityDocuments Removals


Remove (Withdrawn): • The Author organisation or the Consumer or the System Operator can look at the document Audit and will see a line item

entry for the document but will not be able to open the document. • The document will be marked with the status of ‘Withdrawn’ for the Consumer and ‘Reinstate’ for the Author organisation. • Only the Author organisation will be able to reinstate the document. • The document will not be returned in the Get Document view or other specialised views. • Other providers who are not the Author, Consumer or System Operator will not see the audit line item at all. • The Author organisation can supersede the document which will bring the document set back into view for all.

Remove (Incorrect identity): • The Author organisation or the Consumer or the System Operator can look at the document Audit and will see a line item

entry for the document but will not be able to open the document. • The document will be marked with the status of ‘Incorrect Identity’ and all above will be able to see this status. None of the

above will be able to reinstate the document. • The document will not be returned in the Get Document view or other specialised views. • Other providers who are not the Author, Consumer or System Operator will not see the audit line item at all. • If the Author organisation attempts to supersede the document that is marked as ‘Incorrect Identity’ they will receive an

error.

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Documents Removals


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Patient consent







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Specifications are available on the website:



https://www.digitalhealth.gov.au/


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Relevant Specifications are available on the web site: www.digitalhealth.gov.au


Pathology Report CDA Specs

Diagnostic Imaging Report CDA Specs

Diagnostic Imaging Report view specs(required for implementing viewing)

Pathology Report view Specs (required for implementing viewing)

Common Clinical Document(applied to all CDA document types)

https://www.digitalhealth.gov.au/


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Pathology Report metadata (summary)

Patient• IHI (mandatory)• Family Name (mandatory)• Address (optional)• Sex (mandatory)• DOB (mandatory)• Indigenous Status “can be set to 'Not Stated‘” (mandatory)

Author• Must be a Health Professional and most likely a Pathologist in charge• Must have, at a minimum, the persons HPI-I, the persons Family name, and

the Organisations they work for HPI-O and name (mandatory)

Requester:• Date of Request (mandatory)• Some Identifier for the requesting person, can be a local code or

a HPI-I (mandatory)• Requester Address (optional)• Requester Telephone / Email (optional)• Requester Family Name is the only mandatory name part• Requester' organisation is optional

Order Identifier:• External order number, only one (optional)

Reporting Pathologist (only one for the Document)• The reporting Pathologist is akin to the author although does not have to

be the same person, it is not literally the person who wrote the report• Must be a healthcare professional, most likely a Pathologist• Must have, at a minimum, a HPI-I, Family name, address, phone number

organisation’s HPI-O and organisation’s name.

Pathology Test Result (1..*) ‘the ordered item e.g. FBC, LFT, MSU)’• Collection Date Time mandatory• Accession number, only one (mandatory)• Test result name (e.g. FBC, LFT) can use local code or PITUS SNOMED-

CT-AU or both• Diagnostic Service Section ID (Department)• Test Result Status = Panel Status (OBR-25)• Observation Date Time (Which is 1 to 1 with Collection Date and Time)


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Diagnostic Imaging Report metadata (summary)

Patient• IHI (mandatory)• Family Name (mandatory)• Address (optional)• Sex (mandatory)• DOB (mandatory)• Indigenous Status “can be set to 'Not Stated‘” (mandatory)

Author• Must be a Health Professional and most likely a Radiologist in charge• Must have, at a minimum, the persons HPI-I, the persons Family name, and

the Organisations they work for HPI-O and name (mandatory)

Requester:• Date of Request (mandatory)• Some Identifier for the requesting person, can be a local code or

HPI-I (mandatory)• Requester Address (optional)• Requester Telephone / Email (optional)• Requester Family Name is the only mandatory name part• Requester‘s organisation name (mandatory)

Order Identifier:• External order number, only one (optional)

Reporting Pathologist (only one for the Document)• The reporting Radiologist is akin to the author although does not have to

be the same person, it is not literally the person who wrote the report• Must be a healthcare professional, most likely a Radiologist • Must have, at a minimum, a HPI-I, Family name, organisation’s HPI-O and

organisation’s name.

Imaging Examination Result (1..*) ‘the ordered item e.g. Abdo, Mamo)’• Image Date Time (mandatory)• Reported Date Time (mandatory)• Exam result name (e.g. Abdo, Mamo) can use local code or SNOMED-

CT-AU or both (mandatory)• Modality can be local code (mandatory)• Anatomical Location Description, text (mandatory)• Test Result Status = Panel Status ‘HL7 V2 OBR-25’ (mandatory)• URL to related information (optional)




My Health Record ViewingGet Document List

• Simple list of all documents within a patient’s My Health Record

• Filters can be applied to remove particular document types

Med

ical

Dir

ecto

r

Ge

nie

Be

st P

ract

ice



Diagnostic Imaging View

• Specific view for Diagnostic Imaging reports

• Provides search for Examination type

Med

ical

Dir

ecto

r



Pathology Report View

• Specific view for Pathology reports

• Provides search for Test Name type

My

Hea

lth

Rec

ord

Pat

ho

logy

Vie

w


Integration tools & development libraries


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• Can display you CDA documents as they will render to the consumers

• Runs the Schematron rules over your CDA documents and reports errors

Clinical Package Validator



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Integration Toolkits and Sample Code



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Healthcare Identifier and PCEHR System (HIPS)

• Designed to assists large health organisations, including health departments, to integrate their suite of clinical and administration systems to the My Health Record system and HI Service

• Middleware product providing proxy web services to the MyHR & HI Service

• Integration via an Enterprise Service Bus (ESB)

• Leverages Patient Administration System (PAS) Admission Discharge and Transfer (ADT) messaging

• Provides HL7 V2 adapters for ORU^R01 messages

• Integrated hospital episodic patient consent service

• My Health Record viewing capabilities



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Healthcare Identifier and PCEHR System (HIPS)

Patient Administration System (PAS)

HIPS

Hi Service

My Health Record

Discharge Summary

System

Laboratory Information System (LIS)

Radiology Information System (RIS)

Enterprise System Bus

(ESB)

Enterprise Patient Master Index (EMPI)

Medication Dispensing

System

Backend & TransportPresentation National Infrastructure



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