the good, the bad and the ugly - chug · the good, the bad and the ugly. hl7 is a standard for...

The Good,The Good,THE BAD

and the Uglyand the Uglyand the Uglyand the Ugly

� HL7 is a standard for electronic data exchange of health information. It defines formats for clinical and financial data to be exchanged.

� Common Types of HL7 Interfaces with Centricity:

Overview

� Common Types of HL7 Interfaces with Centricity:

� Demographics (ADT)

� Scheduling (SIU)

� Notes (MDM)

� Lab Results (ORU)

� Orders (ORM

� Procedures (DFT)

NotesLink Basics� NotesLink interfaces deal with MDM (Medical

Document Management) messages

� MDM messages require a .ht file extension for import to LinkLogic.

Important Elements for NotesLink Interfaces:

import to LinkLogic.

� MDM messages create EMR chart documents with no structured data!

� Document Type� Summary Line� Spacing!

MSH|^~\&|CHUG_MDM|CHUG_MDM|OERPT.POI|POI|20130315||MDM^T02|1042636650-D355|P|2.3|||AL||| EVN|T02|201303151317|||PID|1||TEST123||TEST^PATIENT||19221120|F|||||||||||||||||||||PV1|1|I|^^^PMA||||^TEST^MD1||||||||||^TEST^MD1|||U||||||||||||||||||||||||201302070904|201302080639||||||TXA|1|HP|FT|201303151317||201303151317|201303151315|201303151317|dtes^TEST^DOCTOR^^^^MD^^^^^^NPI|||MEDREC0315-0001||MEDREC20130315-

MDM Message Structure

T^DOCTOR^^^^MD^^^^^^NPI|||MEDREC0315-0001||MEDREC20130315-0001|355|MEDREC0315-0001|DO||UN||||dtst^TEST^DOCTOR2^^^^MDOBX|1|TX|||HISTORY AND PHYSICALYOUR LOCAL HOSPITALHISTORY AND PHYSICAL EXAMINATION TEST,PATIENT DOCTOR TEST, MD DOB: 11/20/1922 CHIEF COMPLAINT: Shortness of breath, dyspnea on exertion. HISTORY OF PRESENT ILLNESS: This is a 90-year-old Caucasian female with aortic stenosiswith CHF secondary to that. PHYSICAL EXAM: The patient is alert, awake, oriented x3. EKG normal. ASSESSMENT AND PLAN: 90 year old who presents with orthopnea, PND, dyspnea on exertion. Her shortness of breath is probably due to increased pleural effusion which is most likely CHF._________________________________DOCTOR TEST, MDTEST/transD: 03/15/13 1315T: 03/15/13 1315|||||||||201303151317|

EVN – Event Type

EVN|T02|201303151317|||

MSH – Message Header

MSH|^~\&|CHUG_MDM|CHUG_MDM|OERPT.POI|POI|20130315||MDM^T02|1042636650-

D355|P|2.3|||AL|||

MDM Message Structure

PID – Patient Identification

PID|1||TEST123||TEST^PATIENT||19221120|F|||||||||||||||||||||

PV1 – Patient VisitPV1 – Patient Visit

PV1|1|I|^^^PMA||||^TEST^MD1||||||||||^TEST^MD1|||U||||||||||||||||||||||||20130207090

4|201302080639||||||

TXA – Transcription Document Header

TXA|1|HP|FT|201303151317|dtes^TEST^DOCTOR|201303151317|201303151315|201303151317|dtes^TES

T^DOCTOR^^^^MD^^^^^^NPI|||MEDREC0315-0001||MEDREC20130315-0001|355|MEDREC0315-

0001|DO||UN||||dtst^TEST^DOCTOR2^^^^MD1

OBX – Observation/Result

OBX|1|TX|||HISTORY AND PHYSICALYOUR LOCAL HOSPITALHISTORY AND PHYSICAL EXAMINATION TEST,PATIENT

DOCTOR TEST, MD DOB: 11/20/1922 CHIEF COMPLAINT: Shortness of breath, dyspnea on exertion.

HISTORY OF PRESENT ILLNESS: This is a 90-year-old Caucasian female with aortic stenosis with CHF secondary to

that. PHYSICAL EXAM: The patient is alert, awake, oriented x3. EKG normal. ASSESSMENT AND PLAN: 90 year old

who presents with orthopnea, PND, dyspnea on exertion. Her shortness of breath is probably due to increased

pleural effusion which is most likely CHF._________________________________DOCTOR TEST, MDTEST/transD:

03/15/13 1315T: 03/15/13 1315 |||||||||201303151317|

Imported MDM Document #1

DOCUMENT TYPE: Comes from the abbreviation in TXA-2.

DOCUMENT TITLE: Comes from the first 64 characters of OBX-5.

LOCATION: Comes from PV1-3.4.

DOCUMENT TEXT: Comes from OBX-5.

MDM messages should be edited to improve the format and spacing of the EMR document. Unedited MDM documents may be difficult to read.

Spacing Improvements� Using line breaks between paragraphs in OBX-5 creates appropriate space

between the document text to facilitate reading and improve the appearance of the report.

� Use \.br\ in OBX-5 to create a hard return in the document.

� Use \.br\\.br\ in OBX-5 to create a line of space in between paragraphs.

OBX|1|TX|||HISTORY AND PHYSICAL\.br\\.br\YOUR LOCAL HOSPITAL\.br\\.br\HISTORY AND PHYSICAL EXAMINATION\.br\\.br\ TEST,PATIENT DOCTOR TEST, MD \.br\\.br\DOB: 11/20/1922 ADM: 02/07/13\.br\\.br\CHIEF COMPLAINT: Shortness of breath, dyspnea on exertion. \.br\\.br\HISTORY OF PRESENT ILLNESS: This is a 90-year-old Caucasian female with aortic stenosis with CHF secondary to that. She cannot walk a couple of feet to go to the bathroom. Chest x-ray revealed increased interstitial markings. \.br\\.br\PAST MEDICAL HISTORY: 1. Aortic stenosis. 2. CHF. 3. Question COPD. \.br\\.br\PHYSICAL EXAM: The patient is alert, awake, oriented x3 in no major distress. EKG shows normal sinus rhythm. \.br\\.br\ASSESSMENT AND PLAN: 90 year old who presents with orthopnea, PND, dyspneaon exertion. The chest x-ray does reveal some increased interstitial markings. Her shortness of breath is probably due to increased pleural effusion which is most likely CHF.\.br\\.br\_________________________________ \.br\\.br\DOCTOR TEST, MD\.br\\.br\TEST/trans\.br\\.br\D: 03/15/13 1315\.br\T: 03/15/13 1315

What a difference a space makes!

Without line breaks in OBX-5:

WITH line breaks in OBX-5:

Adding space after the title in OBX-5 cleans up the Summary line.title in OBX-5 cleans up the Summary line.

Spacing gone wrong� Sometimes line breaks

are inserted at the end of each line of text by external source systems.

Example from source system with 85 character per line limit:OBX|1|TX|||HISTORY: Ms Test is an 81-year-old woman who has chronic atrial fibrillation on an\.br\Holter

monitor. The ventricular response rate goes down to 40 beats per minute. She\.br\also has episodes of rapid

� External systems may have per line character limits that are longer than Centricity’s.

monitor. The ventricular response rate goes down to 40 beats per minute. She\.br\also has episodes of rapid

ventricular response rate. Today, we performed an AV node\.br\ablation, which rendered her completely

pacemaker dependent. She now presents for a\.br\single chamber pacemaker implantation for AV block (due to

AV node ablation).

Looks like this in Centricity, which has a 75 character per line limit:

Fixing bad spacing� Adjust spacing to fit Centricity’s character limit by replacing

the line breaks with spaces. Then insert line breaks between paragraphs only.

Example:OBX|1|TX|||HISTORY: Ms Test is an 81-year-old woman who has chronic atrial fibrillation on an Holter monitor.

The ventricular response rate goes down to 40 beats per minute. She also has episodes of rapid ventricular The ventricular response rate goes down to 40 beats per minute. She also has episodes of rapid ventricular

response rate. \.br\\.br\Today, we performed an AV node ablation, which rendered her completely pacemaker

dependent. She now presents for a single chamber pacemaker implantation for AV block (due to AV node

ablation).

Looks like this in Centricity:

NotesLink Functionality

� Aesthetically pleasing

� No Flowsheet mappingmapping

� No clinical tracking

� Cannot be pulled into Letter Templates

� Data cannot be reported on

� LabLink interfaces deal with ORU (Observation Result Reporting) messages.

� ORU messages require a .hr file extension for import to LinkLogic.

LabLink Basics

to LinkLogic.

� ORU messages create EMR chart documents with structured data!

Important Elements for LabLink Interfaces:

� Mapping!

� Document Type

� Summary Line

� Cross Reference Files

� Routing

� Overlay

� Priority

� Footer

� MSH – Message Header� MSH-3 or MSH-4 is the LinkLogic Relationship� MSH-11 must be P for the message to import

� PID – Patient Identification

ORU Structure & Important Elements

� PID – Patient Identification� PID-2 is the external patient ID� PID-3 is the internal patient ID� PID-5 is the patient name� PID-7 is the patient’s DOB� PID-8 is the patient’s sex

� NTE – Notes and Comments� NTE-3 contains order notes that are NOT saved as discrete

data

LinkLogic patient matching can be set up to match on External ID AND (Last Name or DOB) or on First Name, Last Name, DOB AND Sex.

� PV1 – Patient Visit

� PV1-3.4 must match an EMR Location of Care abbreviation

� ORC – Common Order

� OBR – Observation Request

� OBR-2 contains the Order Number


� OBR-2 contains the Order Number

� OBR-4 is the Test Name

� OBR-7 is the Clinical Date of the document

� OBR-16 is the Ordering Provider, and the user to whom the document will be routed

� OBR-18 is the Document Type abbreviation

� OBR-25 is the Order Status

� OBR-28 is the “Copies to” field, used for secondary routing

� OBX – Observation/Result� OBX-3 is required and contains the OBS term code and

name, if the result is to be mapped to the Flowsheet

� OBX-5 is the Observation Value, or the result itself

� OBX-6 contains the Units


� OBX-6 contains the Units

� OBX-7 is the Reference Range

� OBX-8 contains Abnormal Flags and determines priority of the document

� OBX-11 is the Observation Result Status

� OBX-14 is the Date/Time of the Observation

ORU Import: Technically Successful

DOCUMENT TITLE: Only includes the first Only includes the first test name

MAPPING: Results aren’t mapped to the Flowsheet

“Results Below…”: Text is repeated before every 17+ character result

Lab Report Footer: Technically Successful(1) Order result status: Final

Collection or observation date-time: 03/27/2013 08:47

Requested date-time:

Receipt date-time: 03/27/2013 08:47

Reported date-time:

Referring Physician:

Ordering Physician: Doctor Test (DTES)

Specimen Source:

Source: CHUG LAB

Filler Order Number: 1010442

Lab site:

Producer ID *1:CHUGLabs


LAB SITE: Lab where test was performed is blank.


(2) Order result status: Final




Reported date-time:



Specimen Source:

Source: CHUG LAB


Lab site:

Producer ID *3:MayoClinic



PRODUCER ID: Listed once for every result, elongating the printed document!

MAPPING: All unmapped results are listed in the footer, elongating the printed document!

The following results were not dispersed to the flowsheet:

PT, 10.0 seconds, (F)

INR, 5.5, (F)

Color, yellowish brownish, (F)

Apperarance, partly clear and partly cloudy, (F)

Blood, Some trace amounts of blood are present in the specimen, (F)

Lab Report & Footer ImprovementsDOCUMENT TITLE: Only includes the first test name

MAPPING: Results aren’t mapped to the FlowsheetFooter is elongated with unmapped results

Use the Summary2.ixp protocol file to

include multiple test names in the Summary

line. Test names are found in OBR-4.2.

Create a Cross Reference File that maps lab

result codes found in OBX-3 to GE

Observation Term codes. Associate that .xrf

with the interface in LinkLogic Task Options.unmapped results

“Results Below…”: Text is repeated before every 17+ character result

LAB SITE: Lab where test was performed is blank.

PRODUCER ID: Listed once for every result, elongating the printed document!

with the interface in LinkLogic Task Options.

Use the nrf.ixp protocol file to remove

“Results Below…” text when result values in

OBX-5 are greater than 17 characters.

Include Lab Site information in OBR-20.

Blank out OBX-15.

Lab Report & Footer Improvements





Reported date-time:


Ordering Physician: Doctor Test (DTES)Ordering Physician: Doctor Test (DTES)

Specimen Source:

Source: CHUG LAB


Lab site: Location: NSMC,North Shore Medical Center

Laboratory,81 Highland Ave,Salem,MA,01970





Reported date-time:



Specimen Source:

Source: CHUG LAB


Lab site: Location: NSMC,North Shore Medical Center

Laboratory,81 Highland Ave,Salem,MA,01970

LabLink: The UGLYThe UGLYThe UGLYThe UGLYWRONG DOCUMENT TYPE

When OBR-18 is blank, the document type defaults to Lab

Report.

ONE OBX PER LINE OF TEXT CHARACTER LIMIT > 75

Creates unique result lines that extend onto a second line of

text, making the report difficult to read.

“Result Below…” REPEATED FOR EVERY LINE OF TEXT

Clutters the report and makes it difficult to read.

SAME OBX-3 VALUE FOR ALL OBX SEGMENTSUNMAPPED RESULTS

Each OBX-5 value overwrites the one before it and is listed in the footer. Unmapped results are also listed in the footer, elongating

the document.

Insert the appropriate document type abbreviation in

OBR-18.

Concatenate OBX-5 values to create a single OBX segment.

Only add \.br\ where

LabLink: Fixing UGLYUGLYUGLYUGLY

Only add \.br\ where hard returns are appropriate.

“Result Below…”Add nrf.ixp configuration file in

LinkLogic Task Options.

Use a cross reference file to map the OBX-3 value to an OBS Term

Code.

LinkLogic Basics

� To set up and configure

LinkLogic allows you to set up, configure, monitor and troubleshoot interfaces into and out of EMR.

� To set up and configure

interfaces in EMR, click

� Go > Setup >

Settings > LinkLogic

NotesLink LinkLogic Setup� Relationships

Each NotesLinkinterface needs a Document Import relationship with a unique name set

� Task Options

unique name set up in LinkLogic.

� Create single document from multiple OBX segments

� Enable document overlay

LabLink LinkLogic Interface Kits� LinkLogic does not allow you to create your own

unique name for a LabLink interface relationship. Instead, you must import an Interface Kit (.ikt) to generate the unique name

LinkLogic Interface Kit Example:

[LLREL][0][CHUG LAB][CHUG LAB RESULTS][Import][Lab Results][HL7][][]

LinkLogic Interface Kit Example:

LinkLogicRelationship

Name

LinkLogicRelationship Description


Direction


Type

Go > Setup > Settings > LinkLogic> Import Interface Kits

LabLink LinkLogic Relationships� Relationships

•Each LabLinkinterface needs a LabResults Import LabResults Import relationship.

•Choose the Unique Name from the drop-down list generated by the interface kit import.

� Task Options

LabLink LinkLogic Task Options

ENABLE

DOCUMENT OVERLAYDOCUMENT OVERLAY

Don’t clog the chart with copies of the same report!

ALLOW NON-EQUIVALENT UNIT

CONVERSIONS

Example: 5L = 5000mL

Document Overlay� In order for different versions of the same document to

overwrite each other, rather than create separate documents in the EMR, Document Overlay must be enabled.

OBR-3 and OBR-4 values in all message versions must be the same.

OBR-7 values or OBR-14 values, if used, in all message versions must be the same.

in all message versions must be the same.

if used, in all message versions must be the same.

OBR-25: "F" cannot be replaced by anything other than "F," "C," or "X".

Overlaid documents must contain the same tests (OBR segments) as the original version. New OBR segments can be added as long as the original OBR segments are included in subsequent versions.

Overlaid documents must contain the same Observation Identifiers (OBX-3) as in the original version. New OBX segments can be added as long as the original OBX segments are included in subsequent versions.

OBX-14 values, if used, in all message versions must be the same.

� LabLink LinkLogic Import Relationships require the use of a cross reference (.xrf) file.

� Cross-reference files translate:� Provider name codes to EMR User IDs

� Lab system (LIS) result codes to EMR OBS Terms

Clinic codes to EMR LOCs

Cross Reference Files for Mapping

� Clinic codes to EMR LOCs

� Located in the llogic\config\local folder

Cross Reference File Sample:H,xrf,Lab Result Heading Conversion Cross Reference,3.0,20060110165040

F,ResultID

/-/ This XRF file was generated with LinkLogic Version LinkLogic 5.6.4_1 \-\

IX,100,MLI-16251

IX,110,LOI-0789-8

IX,113.1,MLI-4306

100,MLI-16251

110,LOI-0789-8

113.1,MLI-4306

Creating a Lab Results Cross Reference File

� In NotePad, create a file listing external result codes, followed by a comma and the GE OBS Term Code.

� Save with a .xrs file extention.

� Create a New Configuration file

� Select the .xrs file for the Input

� Select Lab result codes

Protocol Files� Protocol files (.ixp Import Export Protocol) alter

the behavior of one or more interfaces or fields within interfaces.

Helpful .IXP Files:

Add .ixp files to

an interface in

the Configuration

Files section of

LinkLogic Task

Options.

Managing LinkLogic Errors� Sometimes HL7 messages don’t follow the rules for

successful import into Centricity.

� Use the LinkLogic module of EMR to manage errors, monitor message activity and import or export manually.

Common LinkLogic ErrorsUnable to Identify Patient

Click the Error and then on the Activity below to get more

information.

You can also double-click the error to display the full

message and error.

Use message information and chart research to

identify the correct patient.

Unable to Identify PatientClick Resolve

and then Set Patient.

Find the correct patient.

Click OK, OK to send the document to that patient’s chart.

Common LinkLogic ErrorsInvalid Field Type

• Double-Click the error to display the message and error text.

• Read the error, located between the /-/ and \-\ characters.

• Fix the error in the WordPad window and click the Save button. • Close the WordPad window and click Resolve to reprocess the message without error.

Common LinkLogic ErrorsField Too Long – Value Exceeds Character Limit

• Double-Click the error to display the message and error text.

• Read the error, located • Read the error, located

between the /-/ and \-\characters.

• Fix the error in the WordPad window and click the Save button.

• Close the WordPad window and click Resolve to reprocess the message without error.

Conclusion

�By now you should be able to:

� Understand the steps to creating a functional clinical interface with Centricity EMR

� Identify the interface elements required for technical import and those necessary for clinical workflow efficiency, and understand the difference between the two!

� Decipher and resolve LinkLogic errors common to new interfaces

the good, the bad and the ugly - chug · the good, the bad and the ugly. hl7 is a standard for...

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