Order interaction for the creation of a document

Summary

This proposal documents a new set of HL7 version 3 interactions related to 'ordering the creation of a document'. The newly created set of interactions should be part of a new Topic in the RCMR (medical records) domain. The medical records domain is the responsability of the Structured Documents WG.

Use-case

• Sending an order to request for the (human) creation of a clinical summary report; sending an order to request the creation (by a software application) of a lab result report.

Dynamic Model

In terms of Dynamic Model and Trigger Events the newly proposed Topic conforms to the general Orders and Requests Pattern as defined by the Orders and Observations WG. That design pattern will be used as the basis for this topic.

Static Model

The static model used in the order interactions has to indicate various items of metadata related to the document that should be created (e.g. requested document type, requested author, requested templates the document should conform to, patient id, etc.).

Requirements related to the static model:

• The basic model (refined by further discussions) could be defined to be the CDA Header model, with the focal DOCCLIN Act in RQO mood.
• The final model should be in compliance with the Composite Order model (as defined by the Orders and Observations WG).

The model should allow the ordering party to specify:

• The requested document type
• An interval of time for the data which should be reported on/documented
• The encounter.ID of the encounter which should be reported on/documented
• Identifier of the main (focal) requested/performed act
• Status code of the main (focal) Act. Example: when sending a lab order jointly with an order to create a document with the labresults, one may want to specify that a document should only be created once the status of the lab observation is 'completed' - and nothing before that point in time.
• Patient ID
  • Patient Identifier
  • Secundary identifying characteristics: patientAdministrativeGender, patientBirthTime, patientName
• Who is asked to create the report (person/organization/software application)
• Set of template IDs the document creator is requested to adhere to

See Also

• Vassil: If one were to look at methods outside of HL7,
  • one method could be the IHE ITI Registry Stored query (transaction 18): [1]
  • As a matter of fact, this year a change to the XCA profile [2] is going to introduce the concept of query to create a document on demand to transaction 38, Cross Gateway Query (which is based on transaction 18) - this seem to cover the case for "order for a document"...
• Christof: QED - Query For existing Data, QBD query for bulk data.
• René: the above ITI-18/ITI-38 and profiles are related to querying pre-existing documents. That isn't the case here. Some of the query parameters used in the query for-existing-document-characteristics are appropriate in the order interaction proposed on this page.
• René: the same arguments apply to QED and QBD. In general (and this is probably the communality noticed by both Vassil as well as Christof): 'document metadata' is at the core of the document query interactions they refer to, and certainly 'document metadata' is a strong candidate for being considered to be included in the payload of the newly proposed order interaction.
• Vassil: It is a change proposal, accepted to be worked on during this cycle: CP-ITI-401.
• René: OK, this does discuss the creation of new documents. If one queries another 'affinity domain' (in IHE terms) the other domain may interpret a query as an order to create the document. This is a business arrangement which may exist between affinity domains. Sure: interpreting a query for a document as an order to create such a document may work in some settings. Some of the parameters used in a document query will be applicable in a document order, but other than that I don't think the IHE references provide us with a lot of useful information about the ordering of documents.