HB 235-2007

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.

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).

First published as HB 235-2007.