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  • HB 235-2007

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    Implementers guideline for HL7 referral, discharge and health record messaging

    Available format(s):  Hardcopy, PDF 1 User, PDF 3 Users, PDF 5 Users, PDF 9 Users

    Withdrawn date:  19-09-2019

    Language(s):  English

    Published date:  18-10-2007

    Publisher:  Standards Australia

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    Abstract - (Show below) - (Hide below)

    Provides guidance on AS 4700.6-2006 and covers implementation of the Health Level Seven (HL7) Version 2.4 protocol, for communication of clinical patient-centred information between health service providers in Australia. This Handbook is specifically applicable to clinical communications covering Discharge, Shared Care, Event Summaries, and notification of Shared Electronic Health Record Systems.

    Scope - (Show below) - (Hide below)

    This Handbook covers implementation of electronic referral messages using the HL7 Version 2.4 protocol with local extensions, which will be proposed for inclusion in a later version of HL7 2.X. It covers communication between health service providers both within and outside hospitals including communication for shared care and on discharge, other event summaries and notifications to shared electronic health record and clinical decision support systems. AS 4700.6-2006 includes the data segments and data elements that are mandatory (required), optional or conditional (required, based on a condition), and relevant usage notes in the Australian health environment. It provides consistent use of data definitions as well as commentary and references to the International Organisation for Standardization (ISO), the National Health Data Dictionary (NHDD), the National Association of Testing Authorities Australia (NATA), The General Practice Computing Group (GPCG) and its General Practice Data Model and Core Dataset (co-sponsored with the Commonwealth Department of Health and Ageing). This Standard deals with representation of clinical information for purposes of sharing and transferring patient care. There may be additional administrative, financial, and eligibility aspects of referral which are outside the scope of this Handbook. The message structure described in this Handbook is intended to communicate information from one clinical provider or organisation to another (potentially via a shared electronic health record) and should be used wherever there is a complete or partial transfer of care, as occurs on discharge from a hospital or other care provider. Where used for transfer of care, the message will typically contain referral details as well as a discharge or other event summary. Clinical management by cooperating providers, mandates health service messaging built on agreed semantic exchange. The above groups are actively participating in developments in this evolving area. While the message protocols described in this Handbook employ a required level of coding as in the HL7 tables, they do not specify any particular controlled vocabulary for the broader area of clinical concept representation. A logical next step in terminology agreement should address the headings used in referral, and a code set such as LOINC or SNOMED CT should be considered for this. The HL7 messages detailed here have the capability but not the requirement of exchanging clinical data, and the segments have the capacity to include flexible structures containing both coded and free-form representations. This Standard is applicable across clinical domains, and is intended to be used for communication between providers and organisations with different information models and datasets. This will present a challenge to the exchange of structured clinical information, which will be required for a richer utilization of health information. Such a level of semantic exchange will enable processing aimed at supporting clinical decision making for optimal health outcomes. It is for this purpose that the referral message has been designed to optionally include segments covering the more complex clinical situations reflected in Problems, Goals, and Pathways. It is not however dependent on standardised clinical datasets, and is therefore immediately applicable. The REF is a general clinical communication, which carries health record information, including past history, family history, allergies, medications and medication history, social status, problem, goal and other management details as well as the requested services, which constitute the reason for referral. Referral involves the transfer of care in part (e.g. request for an opinion or a specialized service accompanied by relevant health event summary and record extracts) or in whole (e.g. transfer from one GP practice to another with complete health record data and summary).

    General Product Information - (Show below) - (Hide below)

    Committee IT-014
    Document Type Handbook
    Product Note Withdrawn 19-09-2019.
    Publisher Standards Australia
    Status Withdrawn

    History - (Show below) - (Hide below)

    First published as HB 235-2007.

    Standards Referenced By This Book - (Show below) - (Hide below)

    AS 4846-2006 Health Care Provider Identification
    AS 4700.1-2006 Implementation of Health Level Seven (HL7) Version 2.5 - Patient administration
    AS 4700.6-2004 Implementation of Health Level Seven (HL7) Version 2.3.1 - Referral and discharge summary
    AS 4700.3-2005 Implementation of Health Level Seven (HL7) Version 2.4 Electronic messages for exchange of information on drug prescription
    AS 4700.7-2005 Implementation of Health Level Seven (HL7) Version 2.3.1 - Diagnostic imaging orders and results
    AS 1340-1975 Symbols for SI units for systems with limited character sets
    AS 4700.2-2004 Implementation of Health Level Seven (HL7) Version 2.3.1 - Pathology orders and results
    AS 4700.1-2005 Implementation of Health Level Seven (HL7) Version 2.4 - Patient administration
    HB 262-2002 Pathology electronic messaging - Guidelines for pathology messaging between pathology providers and health service providers - Implementation guide
    AS 4700.6-2006 Implementation of Health Level Seven (HL7) Version 2.4 - Referral, discharge and health record messaging
    AS 4700.1-1998 Implementation of Health Level Seven (HL7) Version 2.3 - Patient administration
    AS 5017-2006 Health Care Client Identification

    Standards Referencing This Book - (Show below) - (Hide below)

    TR 2965-2007 Harmonisation of HD and EI data types across AS 4700.X Standards and associated Handbooks
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