1. HL7 A.2 Messaging within Wales Karen Winder North Glamorgan NHS Trust

2. The need for standardisation of message exchange  1999 saw the formation of Cervical Screening Wales - CSW  A National Service for managing the Cervical Screening program in Wales requiring data in a standard format from all Welsh legacy pathology systems  Information requirement for smear takers and screeners opinions in conjunction with the patients results  Simple delimited flat file was suitable for basic data transfer but complex histology and cytology pathology results required a more structured message – HL7UK A.2

3. Repository synchronisation  Multiple National Services now utilise these messages for surveillance and screening purposes  Standardising on the HL7UK A.2 message allows:  Pathology systems at all Welsh Trusts to transfer data in the same message structure  One interface engine to receive the messages and feed several repositories  Weekly downloads of authorised histology to:  Breast Screening Wales  Cervical Screening Wales  Welsh Cancer Intelligence Surveillance Unit

4. Progress to real time messages for database synchronisation  Use the functionality within the HL7 message for real time data base synchronisation from all pathology disciplines  This enables additional applications such as:  Data repositories for access to pathology and radiology results which supplies clinicians with up to date status information on requests and results  Transfer of pathology results to CANISC (the Cancer data repository for Wales) to provide continuity of care

5. Breast Screening results to GP using HL7 A.2 messages  Breast screening currently generates thousands of paper reports per GP surgery each cycle  These reports are then manually typed into the GP system  This process is currently being replaced in Wales by HL7 A.2 messages generated from the National Breast Screening System and sent out via Middleware and DTS to the GP systems  The scope of the project currently includes normal results, DNAs and decliners  It will be extended to include Bowel Screening results later next year

6. Results to Requesting  2006 saw the development of an in-house electronic ordering solution for pathology  This extended the functionality of the legacy pathology systems to include HL7UK A.2 orders as well as results  It encompasses both primary and secondary care ordering  Disciplines currently in scope are Biochemistry, Haematology and Microbiology

7. Welsh Clinical Portal and Test Requesting and Results Reporting  Test Requesting and Results Reporting (TRRR) in the Welsh Clinical Portal is making use of the developments at Trust level using A.2 as the standard for orders and results.  A number of new components are also being developed, including the portal’s user interfaces and the National Pathology Handbook.

8. Messaging Fabric Institution-based System (Hospital)Institution-based System (Hospital) Pathology Service Clinical Portal Services Clinical Portal Services Clinical Portal Services Clinical Portal Services Requests Results Orders Request Monitor Order Monitor Laboratory System Inbound message queue Biochemistry Microbiology Haematology Outbound message queue Print engine PAS database Traditional PAS interfaces PAS adapter National pathology handbook

10. NHS Wales Clinical Portal Peter Nicklin HL7 UK Annual Conference, November 2007

11. NHS Wales Topics: NHS Wales National Architecture NHS Wales Clinical Portal Clinical Communications and CDA.

12. NHS Wales Topics: NHS Wales National Architecture NHS Wales Clinical Portal Clinical Communications and CDA.

13. NHS Wales National Architecture Objectives: Provide a migration path for NHS Wales health systems from “where we are now” to a common framework, enable communication between clinical services within an organisation (short term), enable communication between organisations (longer term), adapt to radical changes in organisation structures (mergers, specialisations etc.), protect privacy and confidentiality.

14. NHS Wales National Architecture Infrastructure: information design for what information will be exchanged, SOA: how information will be exchanged, connectivity with existing systems, identification of patients, users, and organisations, security and control of the use of information.

15. Institution-based System (Hospital) PAS Pharmacy Pathology Radiology Other systems 5 Institutional Messaging Fabric National Messaging Fabric Institution-based System (Hospital) Patient Record Services 2 Patient Record Services Patient Record Services Other systems Other systems Clinical Portal Services Clinical Portal Services Clinical Portal Services Clinical Portal Services Gateway Services 4 Gateway Services Gateway Services Authentication Services Authentication Services Authentication Services Demographics Services Demographics Services Demographics Services linked together by the messaging fabric. the Welsh Clinical Portal, Adapters to existing departmental systems, develop the local patient record NHS Wales National Architecture - Local NHS Wales National Architecture - National national services need a national messaging fabric national services and gateways to external systems

16. NHS Wales Topics: NHS Wales National Architecture NHS Wales Clinical Portal Clinical Communications and CDA.

17. NHS Wales Clinical Portal Objectives: clinical communications and correspondence, view an individual's records, request, prescribe, report, track, document care.

18. NHS Wales Clinical Portal Phases: foundation phase: –lists and basic patient information, –pathology requests and results. further phases: –radiology requests and results, –referral and discharge comms. (+ clinic letter), –transcription of medicines, –etc..

19. NHS Wales Clinical Portal Approach: Requirements and design: –User Centred Design sessions, –heavy emphasis on clinical needs, –captured in the Generic Information Framework for the Individual Record (GenIFIR). Iterative. Services & phases based on: –user requirements as they are gathered, –feedback from clinical use of the Portal.

20. NHS Wales Topics: NHS Wales National Architecture NHS Wales Clinical Portal Clinical Communications and CDA.

21. Institution-based System (Hospital) PAS Pharmacy Pathology Radiology Other systems 5 Institutional Messaging Fabric National Messaging Fabric Institution-based System (Hospital) Patient Record Services 2 Patient Record Services Patient Record Services Other systems Other systems Clinical Portal Services Clinical Portal Services Clinical Portal Services Clinical Portal Services Gateway Services 4 Gateway Services Gateway Services Authentication Services Authentication Services Authentication Services Demographics Services Demographics Services Demographics Services NHS Wales Clinical Communications access to external patient records

22. Clinical communications Demands: complex clinical info.: diagnoses, signs & symptoms, medications, results etc., linked information, identity: attribution, provenance, creator, the individual, domains: identification, code sets, flexibility, the capacity to reorganise information (into a new document), longevity; all information must have a human-readable form, usability, stability.

23. CDA Characteristics HL7 CDA Release 2.0, 28 th July 2003 Persistence – A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements.[1][1] Stewardship – A clinical document is maintained by an organization entrusted with its care. Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated. Context - A clinical document establishes the default context for its contents. Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document. Human readability – A clinical document is human readable...from elsewhere…(Human readability applies to the authenticated content. There may be additional information conveyed in the document that is there primarily for machine processing that is not authenticated and need not be rendered.) ………………. Pre-formatting documents: –section level templates –entry level templates …............................... Provenance (paraphrased): authoriser, transcriber, doer, etc.. [1][1] There is a distinct scope of persistence for a clinical document, independent of the persistence of any XML-encoded CDA document instance.

25. Major components of a CDA document:... CDA Header............

26. Context