HL7 Interface Specifications Merge AIMS 8 · PDF fileHL7 Interface Specifications Merge AIMS 8.3 ... Inbound Interface Functionality ... Supported SIU Event Types

HL7 Interface SpecificationsMerge AIMS

8.3

Merge Healthcare900 Walnut Ridge Drive

Hartland, WI 53029 USA

877.44.MERGE

© 2012 Merge Healthcare. The information contained herein is confidential and is the sole property of Merge Healthcare. None of the information may be reproduced, copied, and/or re-distributed electronically, manually, or otherwise to any person without advance written permission from Merge Healthcare, except as may be expressly authorized by contracts or other agreements between Merge Healthcare and its customer. Merge Healthcare® and AMICAS are registered trademarks and VERICIS, RadSuite, Abraxas, and iConnect are also trademarks of Merge Healthcare. Other trademarks or service marks referred to herein are the property of their respective owners.

Doc # Revision Date Description

AIMS-1068 1 10/15/12 Initial release for 8.3.

Contents

Inbound Interfaces

Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

HL7 Version Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Inbound Interface Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Admit/ Discharge- ADT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Supported ADT Event Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Scheduling - SIU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Supported SIU Event Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Lab Results - ORU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Supported ORU Event Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Outbound Interfaces

Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

HL7 Version Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Charge Utilization - DFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Charge Utilization Interface Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

DFT^P03 Message Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Charge Utilization Message Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Post Case - ORU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Post Case Interface Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

ORU^R01 Message Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Post-Case Message Example. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Clinical Data - Outbound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Clinical Data Interface Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

HL7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Clinical Data Message Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Clinical Data Message Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

i

Merge AIMS 8.3 HL7 Interface Specification

ii

1

Chapter 1 Inbound Interfaces

The Merge Healthcare Anesthesia Information Management System (AIMS) supports three types of inbound interfaces: ADT, Scheduling, and Lab Results. This portion of the document defines the interface specifications that support the transmission of data from the HIS system to the AIMS system. The specific HL7 events supported by the AIMS system as well as the fields to which the data are assigned within the application are defined.

Communication● Protocol: TCP Streaming Sockets (WinSock2 TCP Socket)

● Port Number: The AIMS system accepts all inbound connections through one configurable port.

● Acknowledgement Sent: Commit-level MSA structure

HL7 Version SupportThe Merge Healthcare AIMS system currently supports HL7 versions 2.1 to 2.4 for all inbound ADT, SIU, and ORU messages.

Inbound Interface FunctionalityHL7 messages can be routed from various hospital systems into the HIS HL7 engine on multiple sockets, and then into the HL7 Inbound Interface on a single socket connection. Conversely, multiple senders can send directly to the interface using the same destination IP address and port number, where no HL7 engine is available. The interface accepts unsolicited HL7 messages over a TCP streaming socket and returns a commit-level HL7 ACK on the same socket. Application-level ACK and custom error messages are not supported (for example: delayed acknowledgement on a different socket). The HL7 Inbound Interface is unidirectional.

HL7 event types will control the behavior of the message processing. The message handling logic will follow different paths depending upon the particular message's event type. Messages with event types not configured for processing will be discarded.

The Interface will decide which logical path to follow based upon the event type of the message found in the HL7 message header segment (MSH: 9). The parser will then find the various data elements within the segments of the message and send the information into SQL

1


Server. A message lacking the system's required fields will not be processed into the database.

The HL7 Inbound Interface can be configured to populate the various fields in the SQL Server database from virtually any HL7 message element. The base configuration has been adequate for most installations, but adjustments to the base mappings can be made to suit a particular situation. Actual configuration settings will be negotiated between the HIS department and the Merge Healthcare development team during implementation.

Admit/ Discharge- ADTThe ADT information is used to update the patient demographic and visit information in the AIMS system database. This information can be viewed and/or updated manually through the AIMS PAE and AIMS Anesthesia products. Any changes to the patient's demographic and/or visit information recorded through the HIS system will automatically update the database such that the data will be available through AIMS PAE and AIMS Anesthesia. These are some of the benefits of having an ADT interface:

● Patient demographics and visit information will be available to the OR in a timely fashion

● Updates to patient information are available immediately

Supported ADT Event Types

The Merge Healthcare AIMS system currently supports these ADT event types to:

● Create new patient record

● Update patient record

● Merge patient records

Trigger Event Definition Action

ADTÂ01 Admit a Patient If patient record does not exist in the AIMS system, it is created.

ADTÂ02 Transfer a Patient If patient record exists, it is updated; otherwise, the record is created.

ADTÂ04 Register a Patient If patient record exists, it is updated; otherwise, the record is created.

ADTÂ05 Pre-Admit If patient record exists, it is updated; otherwise, the record is created.

ADTÂ06 Transfer an Outpatient to Inpatient

If patient record exists, it is updated; otherwise, the record is created

ADTÂ07 Change Inpatient to Outpatient

If patient record exists, it is updated; otherwise, the record is created

2


ADTÂ08 Update Patient Information

If patient record exists, it is updated; otherwise, the record is created.

ADTÂ13 Cancel Discharge If patient record exists, it is updated; otherwise, the record is created.

ADTÂ18 Merge Patient Information

This merge event is non-specific and is retained in HL7 for backwards compatibility. It is supported by the system; however, exact functionality is determined on an individual basis with accounts

ADTÂ34 Merge Patient - Internal ID (MRN)

If prior MRN is found in our system, it will be changed to the "surviving" MRN, or merged with the "surviving" MRN if that already exists.

ADTÂ35 Merge Patient Information - Account Number

If prior Account is found in our system, it will be changed to the "surviving" Account, or merged with the "surviving" Account if that already exists.

ADTÂ36 Merge Patient Information


ADTÂ40 Merge Patient - Internal ID (MRN)


ADTÂ41 Merge Patient Information - Account Number


ADTÂ42 Merge Visit - Visit Number

Visit number update

ADTÂ44 Move Account Account will be moved to, or created on, the specified MRN

ADTÂ45 Move Visit Visit number update

ADTÂ47 Change MRN If prior MRN is found in our system, it will be changed to the "surviving" MRN, or merged with the "surviving" MRN if that already exists.


3


HL7 Definitions

The Merge Healthcare AIMS system currently supports these segments for HL7 ADT messages:

ADTÂ49 Change Account Number


ADTÂ50 Change Visit Number Visit number update

ADT^P01 Add Patient Account If patient record exists, it is updated; otherwise, the record is created.

ADTÂ60 Add/Update/Delete Patient Allergy

Properly drug-framework codified patient allergies will be updated in the patient record.


1. MSH Message Header

2. PID Patient Identification

3. PV1 Patient Visit

4. DG1 Diagnosis

5. IN1 Insurance Info

6. OBX Observation

7. NTE Notes and Comments

8. ORC Common Order

9. RXE Pharmacy/Treatment Encoded Order

10. RXR Pharmacy/Treatment Route

11. MRG Patient Merge

12. AL1 Patient Allergy

13. IAM Patient Allergy (A60)

4


Within each supported segment, the system can capture and process these elements:

Table 1-1: MSH Definition

Segment Field SubfieldReq/Opt/Cond

HL7 Definition Comment

MSH 1 R Field Separator |

MSH 2 R Encoding Characters Literal "^~\&"

MSH 3 O Sending Application

MSH 4 O Sending Facility

MSH 9 1 R Message Type ADT

MSH 9 2 R Trigger Event A01-A60

MSH 10 R Message Control ID Unique Message ID

MSH 12 R HL7 Version 2.1 to 2.4

Table 1-2: PID Definition



PID 2 O External ID

PID 3 1 R Patient MRN

PID 5 1 R Patient Last Name

PID 5 2 R Patient First Name

PID 5 3 O Patient Middle Name

PID 7 O Patient Date of Birth Format: YYYYMMDD

PID 8 O Patient Sex

PID 18 R Patient Account Number

PID 19 O Patient SSN Number Format: XXX-XX-XXXX

5


Table 1-3: PV1 Definition



PV1 2 O Patient Class I, O, U (Inpatient, Outpatient, Unknown)

PV1 3 4 O Patient Facility

PV1 5 O Pre-admit Number Prior T Account Number

PV1 10 O Hospital Service

PV1 17 1 O Admitting Doctor ID

PV1 17 2 O Admitting Doctor Last Name

PV1 17 3 O Admitting Doctor First Name

PV1 17 7 O Admitting Doctor Degree

PV1 19 1 O Patient Visit Number

PV1 44 O Admit Date/Time Format: YYYYMMDDHHmm

PV1 50 O Alternate Visit ID Prior T Account Number

Table 1-4: DG1 Definition



DG1 1 O Set ID

DG1 2 O Diagnosis Coding Method

I9, etc.

DG1 3 1 O Diagnosis Code/Identifier

DG1 4 O Diagnosis Description

DG1 5 O Diagnosis Date/Time Format: YYYYMMDDHHmm

DG1 6 O Diagnosis Type A,W, F (Admitting, Working, Final)

6


Table 1-5: IN1 Definition



IN1 2 1 O Insurance Plan ID

IN1 4 1 O Insurance Company Name

Table 1-6: OBX Definition for Height/Weight



OBX 3 1 O Observation Identifier Indicator (Height, Weight, etc)

OBX 5 1 O Observation Value Patient Height or Weight

OBX 6 1 O Observation Units Recognized height units include cm, centimeter(s), mm, millimeter(s), m, meter(s), ft, foot, feet; otherwise inches is assumed.

Recognized weight units include kg, kilo(s), kilogram(s), oz, ounce(s); otherwise pounds is assumed.

Table 1-7: OBX Definition for Surgical History



OBX 3 1 R Observation Identifier External key such as SURG_HX; mapped in System Config utility.

OBX 5 1 R Observation Value Procedure name or description

OBX 7 1 O Reference Range Anesthesia Type; mapped in System Config utility

7


OBX 8 1 O Abnormal Flags "Y" for complications checkbox; other flags ignored.

OBX 11 1 O Observation Result Status

"D" Delete will remove item. "F" Final or "C" Correction (or any other value) will add or update the item.

OBX 14 1 O Observation date-time

Surgical procedure date: "yyyymmddHHMM" or "yyyymmdd"

OBX 15 1 and 3 C Producer's ID and Name of coding system

Internal ID from source system and name of source system.

Conditionally required, necessary to process deletes.

Table 1-8: OBX Definition for Family History of Anesthesia



OBX 3 1 R Observation Identifier External key matching

● None

● Problems

● No Problems

● Unknown

As mapped in System Config utility.

Table 1-7: OBX Definition for Surgical History (Continued)



8


Table 1-9: OBX Definition for NPO Status



OBX 3 1 R Observation Identifier Either of two values

(Date-time value or Since Midnight checkbox) mapped in System Config utility.

OBX 5 1 C Observation Value If Identifier matches to checkbox, then Value field indicates checkbox state (T, True, F False)

OBX 14 1 C Observation date-time

If Identifier matches to date-time, NPO since this date-time

Table 1-10: OBX Definition for PreOp or PostOp Vital Signs



OBX 3 1 R Observation Identifier Group identifier indicating PreOp or Post-Op, as mapped in System Config utility

OBX 4 R Observation Sub-Id Identifies the particular measurements, including:

● Blood Pressure

● Temperature

● Temperature Mode

● Pulse

● Respiration

● SpO2

● Room Air

● Percent Oxygen

The Identifiers are mapped in System Config utility.

9


OBX 5 1 R Observation Value Value of the specific measurement; numeric except for Temperature Mode and Room Air

OBX 6 1 C Units Required for Temperature (F or C)

OBX 14 1 R Observation date-time

Vitals timestamp; the single latest timestamp per set is saved in AIMS.

Table 1-11: OBX Definition for Medical History



OBX 3 1 R Observation Identifier Identifies the particular Condition as mapped in the System Config utility.

OBX 5 1 O Observation Value See note below

OBX 11 1 R Observation Result Status



Timestamp

Table 1-12: OBX Definition for Timed Events



OBX 3 1 R Observation Identifier Identifies the particular Event as mapped in the System Config utility.

OBX 5 1 O Observation Value Can optionally be used instead of OBX-14 for event date-time

OBX 14 1 R Event date-time Timestamp of event

Table 1-10: OBX Definition for PreOp or PostOp Vital Signs (Continued)



10


The patient’s medication profile of Home and Current medications is sent in a RDEÔ11 message. The MSH, PID, and PV1 segments are described above. Each medication must be sent in a separate message, with a single ORC and RXE segment.

Note regarding medical history Value field: The value field is not explicitly required. If all possible medical history items have multiple-choice style answers (T/F, Y/N, selection lists), then it is possible to combine OBX-3 and OBX-5 into a composite identifier, and map those to groups of conditions in PAE. For example, a question "Do You Smoke?" with Y/N answers could map to a PAE "Smoker" and "Non-smoker" conditions.

However, if any medical history items have free-response answers, then it is recommended to map the Value field as the comment associated with the individual question. For example, a question "Who is your cardiologist?" with a text response would map to a PAE "Cardiologist" condition and its associated comment field.

Examples:

OBX|3|TX|NURAASS12^NURSM1^Do you now/did you ever smoke?||Y||||||F|||201206281413

OBX|4|TX|NURAASS12^NURSMH1^Qty.||1:1 pack/day||||||F|||201206281413

Table 1-13: NTE Definition for Surgical History



NTE 3 O Comment Surgical History item Comment

Table 1-14: NTE Definition for Family History of Anesthesia



NTE 3 O Comment Family History Comment

Table 1-15: NTE Definition for NPO Status



NTE 3 O Comment NPO Comment (25 character max)

Table 1-16: NTE Definition for PreOp or PostOp Vital Signs



NTE 3 O Comment Physiologic Status Comment

Table 1-17: NTE Definition for Medical History



NTE 3 O Comment Condition Comment

11


Table 1-18: ORC Definition for Home/Current Medications



ORC 2 1 C Order Identifier Used as the Source ID; necessary to process deletes

ORC 5 1 C Order Status "D" or other configured value will remove item with matching ID, Source, and Source ID

ORC 9 1 C Documentation Date-time

Updates are only processed if newer than existing data

ORC 10 1 C User Name Free text, can also be configured to RXE-13

ORC 21 1 C Ordering Facility Name

Used as Source; necessary to process deletes

Table 1-19: RXE Definition for Home/Current Medications



RXE 1 1-2 O Frequency Free text

RXE 2 1 R Medication Identifier

RXE 2 2 R Medication Description

RXE 2 3 R Identifier Type

RXE 4 1 O Dose Amount Free text

RXE 5 1 O Dose Units Concatenated with Dose Amount

RXE 7 1 O Comment Free text

RXE 18 1 O Last Taken Free text

Table 1-20: RXR Definition for Home/Current Medications



RXR 1 2 O Route Free text

12


Table 1-21: MRG Definition



MRG 2 R Prior Patient ID Prior MRN

MRG 3 R Prior Account Number

Prior Account Number

Table 1-22: AL1 Definition



AL1 2 1 R Allergen Type Code "DA" (Drug Allergy), "FA" (Food Allergy)

AL1 3 1 R Allergen Code/ID

AL1 3 2 R Allergen Code/Text

AL1 3 3 R Allergen Code/Type

AL1 3 4 O Alternate Identifier

AL1 3 6 O Allergy Source System

AL1 5 O Allergic Reaction

Table 1-23: IAM Definition



IAM 2 1 R Allergen Type Code "DA" (Drug Allergy), "FA" (Food Allergy)

IAM 3 1 R Allergen Code/ID

IAM 3 2 R Allergen Code/Text

IAM 3 3 R Allergen Code/Type

IAM 5 O Allergic Reaction

IAM 6 1 O Allergy Action/Identifier

IAM 7 1 C Allergy Unique Identifier

IAM 7 2 C Allergy Source System

13


Scheduling - SIUThe SIU information is used to update the scheduling information in the AIMS system database. This information can be viewed and/or updated manually through the AIMS PAE and AIMS Anesthesia products. Any updates to the surgical procedure scheduling recorded through hospital scheduling system will automatically update the AIMS system database such that the data will be available through AIMS PAE and AIMS Anesthesia. These are some of the benefits of having a scheduling interface:

● Procedure scheduling information will be available to the OR in a timely fashion

● Updates to scheduling information are available almost immediately

● It will eliminate the need to manually enter procedure, scheduling and patient demographics within the system

Supported SIU Event Types

The Merge Healthcare AIMS system currently supports these SIU event types for:

● New scheduled surgery appointment (also known as a "Case")

● Scheduled appointment update

● Scheduled appointment cancellation

IAM 9 1 O Sensitivity to Causative Agent code

"IN" Intolerance

Any other value for a true allergy

IAM 17 1 O Allergy Clinical Status Code





SIU^S12 New Appointment (Surgical Procedure)

Case record is created. This includes patient information. If patient record exists, it will be attached and updated as needed.

SIU^S13 Reschedule Surgery If case record exists, it is updated; otherwise, the record is created.

SIU^S14 Change Surgical Appointment Details

If case exists, it is updated; otherwise, the record is created.

SIU^S15 Cancel Surgery Case is canceled

14


HL7 Definitions

The Merge Healthcare AIMS system currently supports these segments for HL7 SIU messages:

Within each supported segment, the system can capture and process these elements:


2. SCH Appointment Identification



5. OBX Event Timestamps

6. NTE Notes and Comments

7. ORC Common Order

8. RXE Pharmacy/Treatment Encoded Order

9. RXR Pharmacy/Treatment Route

10. AIS Surgical Procedure Information

11. AIL Operating Room Location (Scheduled Date/Time)

12. AIP Hospital personnel








MSH 9 1 R Message Type SIU

MSH 9 2 R Trigger Event S12-15



Table 1-25: SCH Definition



SCH 2 1 R Filler Appointment ID Medical Procedure Appointment ID

15





PID 2 O External ID






PID 8 O Patient Sex






PV1 2 O Patient Class I, O, U (Inpatient, Outpatient, Unknown)

PV1 3 4 O Patient Facility

PV1 5 O Pre-admit Number Prior T Account Number

PV1 10 O Hospital Service

PV1 17 1 O Admitting Doctor ID

PV1 17 2 O Admitting Doctor Last Name

PV1 17 3 O Admitting Doctor First Name

PV1 17 7 O Admitting Doctor Degree

PV1 19 1 O Patient Visit Number

PV1 44 O Admit Date/Time Format: YYYYMMDDHHmm

PV1 50 O Alternate Visit ID Prior T Account Number

16


Table 1-28: OBX Definition for Height/Weight



OBX 6 1 O Observation Units Recognized height units include cm, centimeter(s), mm, millimeter(s), m, meter(s), ft, foot, feet; otherwise inches is assumed.

Recognized weight units include kg, kilo(s), kilogram(s), oz, ounce(s); otherwise pounds is assumed.

Table 1-29: OBX Definition for Surgical History



OBX 3 1 R Observation Identifier External key such as SURG_HX; mapped in System Config utility.

OBX 5 1 R Observation Value Procedure name or description

OBX 7 1 O Reference Range Anesthesia Type; mapped in System Config utility

17


OBX 8 1 O Abnormal Flags "Y" for complications checkbox; other flags ignored.

OBX 11 1 O Observation Result Status


OBX 14 1 O Observation date-time

Surgical procedure date: "yyyymmddHHMM" or "yyyymmdd"

OBX 15 1 and 3 C Producer's ID and Name of coding system

Internal ID from source system and name of source system.

Conditionally required, necessary to process deletes.

Table 1-30: OBX Definition for Family History of Anesthesia



OBX 3 1 R Observation Identifier External key matching

● None

● Problems

● No Problems

● Unknown

As mapped in System Config utility.

Table 1-29: OBX Definition for Surgical History (Continued)



18


Table 1-31: OBX Definition for NPO Status



OBX 3 1 R Observation Identifier Either of two values

(Date-time value or Since Midnight checkbox) mapped in System Config utility.

OBX 5 1 C Observation Value If Identifier matches to checkbox, then Value field indicates checkbox state (T, True, F False)

OBX 11 1 C Observation date-time

If Identifier matches to date-time, NPO since this date-time

19


Table 1-32: OBX Definition for PreOp or PostOp Vital Signs



OBX 3 1 R Observation Identifier Group identifier indicating PreOp or Post-Op, as mapped in System Config utility

OBX 4 R Observation Sub-Id Identifies the particular measurements, including:

● Blood Pressure

● Temperature

● Temperature Mode

● Pulse

● Respiration

● SpO2

● Room Air

● Percent Oxygen

The Identifiers are mapped in System Config utility.

OBX 5 1 R Observation Value Value of the specific measurement; numeric except for Temperature Mode and Room Air

OBX 6 1 C Units Required for Temperature (F or C)


Vitals timestamp; the single latest timestamp per set is saved in AIMS.

20


The patient’s medication profile of Home and Current medications is sent in a RDEÔ11 message. The MSH, PID, and PV1 segments are described above. Each medication must be sent in a separate message, with a single ORC and RXE segment.

Table 1-33: OBX Definition for Medical History



OBX 3 1 R Observation Identifier Identifies the particular Condition as mapped in the System Config utility.

OBX 5 1 O Observation Value See note below

OBX 11 1 R Observation Result Status



Timestamp

Table 1-34: OBX Definition for Timed Events



OBX 3 1 R Observation Identifier Identifies the particular Event as mapped in the System Config utility.

OBX 5 1 O Observation Value Can optionally be used instead of OBX-14 for event date-time

OBX 14 1 R Event date-time Timestamp of event

Table 1-35: NTE Definition for Surgical History



NTE 3 O Comment Surgical History item Comment

Table 1-36: NTE Definition for Family History of Anesthesia



NTE 3 O Comment Family History Comment

21


Note regarding medical history Value field: The value field is not explicitly required. If all possible medical history items have multiple-choice style answers (T/F, Y/N, selection lists), then it is possible to combine OBX-3 and OBX-5 into a composite identifier, and map those to groups of conditions in PAE. For example, a question "Do You Smoke?" with Y/N answers could map to a PAE "Smoker" and "Non-smoker" conditions.

However, if any medical history items have free-response answers, then it is recommended to map the Value field as the comment associated with the individual question. For example, a question "Who is your cardiologist?" with a text response would map to a PAE "Cardiologist" condition and its associated comment field.

Examples:

OBX|3|TX|NURAASS12^NURSM1^Do you now/did you ever smoke?||Y||||||F|||201206281413

OBX|4|TX|NURAASS12^NURSMH1^Qty.||1:1 pack/day||||||F|||201206281413

Table 1-37: NTE Definition for NPO Status



NTE 3 O Comment NPO Comment (25 character max)

Table 1-38: NTE Definition for PreOp or PostOp Vital Signs



NTE 3 O Comment Physiologic Status Comment

Table 1-39: NTE Definition for Medical History



NTE 3 O Comment Condition Comment

22


Table 1-40: ORC Definition for Home/Current Medications



ORC 2 1 C Order Identifier Used as the Source ID; necessary to process deletes

ORC 5 1 C Order Status "D" or other configured value will remove item with matching ID, Source, and Source ID

ORC 9 1 C Documentation Date-time

Updates are only processed if newer than existing data

ORC 10 1 C User Name Free text, can also be configured to RXE-13

ORC 21 1 C Ordering Facility Name

Used as Source; necessary to process deletes




RXE 1 1-2 O Frequency Free text

RXE 2 1 R Medication Identifier

RXE 2 2 R Medication Description

RXE 2 3 R Identifier Type

RXE 4 1 O Dose Amount Free text

RXE 5 1 O Dose Units Concatenated with Dose Amount

RXE 7 1 O Comment Free text

RXE 18 1 O Last Taken Free text




RXR 1 2 O Route Free text

23


The first AIS segment becomes the primary procedure. Any subsequent AIS segments will become Additional scheduled procedures for the case. There is no limit on the number of additional procedures for a case.

Multiple staff are supported, in that there can be multiple surgeons, multiple CRNAs, multiple Anesthesiologists, multiple nurses, etc., but the system will determine their role in the case based upon the database setting for that clinician. Typically, only the surgeon is sent across on the schedule; but other team members can be sent as well.

Table 1-43: AIS Definition



AIS 3 4 R Universal Service ID - Code

Medical Procedure Type ID

AIS 3 5 O Universal Service ID - Text

Medical Procedure Type Text

Table 1-44: AIL Definition



AIL 3 2 R Location ID (Room) Medical Procedure Location/Room

AIL 6 1 R Start Date/Time Procedure Date and Time

Format: YYYYMMDDHHmm

Table 1-45: AIP Definition



AIP 3 1 R Personnel ID Medical Procedure Staff ID

24


Lab Results - ORUThe Lab Result information will be sent from the hospital's lab system and stored in the AIMS system database. This information can be viewed in the AIMS PAE and AIMS Anesthesia products. Any changes to the patient's lab result information recorded through either the LIS or the HIS system will automatically update the database such that the data will be available through AIMS PAE and AIMS Anesthesia. These are some of the benefits of having a lab results interface:

● Patient lab results information will be available to the clinician

● Updates to patient lab results information are available immediately

Supported ORU Event TypesThe Merge Healthcare AIMS system currently supports these ORU event types to:

● Populate the lab results

● Update lab results based on Date/Time of observation for each visit

HL7 Definitions

The Merge Healthcare AIMS system currently supports these segments for HL7 ORU messages:


ORU^R01 Unsolicited Lab Result If matching Patient account and lab test type are found in the database, lab results will be added to the patient record.



3. OBR Observation Request Information (Date/Time, etc)

4. OBX Observation (Lab Results)

5. NTE Comments

25


Within each supported segment, the Merge Healthcare AIMS system can capture and process these elements:








MSH 9 1 R Message Type ORU

MSH 9 2 R Trigger Event R01






PID 2 O External ID






PID 8 O Patient Sex



Table 1-48: OBR Definition



OBR 7 R Observation Date/Time

Lab Result Date and Time

Format: YYYYMMDDHHmm

26


Table 1-49: OBX Definition



OBX 1 R Set ID

OBX 2 R Value Type Only "ST" and "NM" will be processed

OBX 3 1 R Observation Identifier Lab Results Lab Type

OBX 5 1 R Observation Value Lab Results Observation Value

OBX 6 1 O Observation Units

OBX 7 O Reference Range

OBX 8 O Abnormal Flag

Table 1-50: NTE Definition



NTE 3 O Comment Lab Results Observation Comments

27


28

2

Chapter 2 Outbound Interfaces

The Merge Healthcare AIMS system supports three outbound interfaces: Clinical Data, Charge Utilization, and the Post Case interface. This portion of the document defines the interface specifications that support the transmission of data from the AIMS system to the client’s interface engine for further processing, or directly to the HIS system(s).

Communication● Protocol: TCP Streaming Sockets

● Target IP address and Port Number: Configurable

● Acknowledgement Received: MSA message structure - commit level acknowledgement (same socket)

HL7 Version Support● Clinical Data Interface: HL7 Version 2.4

● Charge Utilization Interface: HL7 Version 2.3

● Post Case Interface: HL7 Version 2.3.1

Charge Utilization - DFTThis interface is designed to provide information regarding the items and quantities of drugs and supplies used during an anesthesia procedure. These are some of the benefits of having a Charge Utilization interface:

● Billing system, pharmacy and/or materials management will know what was used during an anesthesia case immediately upon close of case.

● Manual paperwork for charging is eliminated.

● Auditing report is available.

29


Charge Utilization Interface Functionality

The HL7 Charge Utilization Interface runs as a Windows service, and communicates with the database via the AIMS system web service, over HTTPS. It polls the database for new utilization data, and sends out HL7 DFT^P03 messages if new data is found.

At the close of an anesthesia case, the system parses out the case data sent in from the AIMS Anesthesia client machine in the OR where the case ran. Some of that parsed data will be entered into the three utilization tables in the SQL database. This will trigger the outbound interface to send out the utilization messages for that case.

The three utilization types are:

● OR Drugs

● IV Bag Solutions

● Supply Items

The outbound interface can be configured to send out any or all of the three utilization types. There will be one HL7 transaction per item type per case. The case utilization data is grouped and aggregated by charge code and Product ID. Overall utilization quantities are calculated for each combination of charge code and Product ID for that anesthesia case. If five different drugs were given during that case, five HL7 transactions are produced - regardless of how many individual syringes were used to deliver those drugs. There will be one HL7 transaction per drug, showing the total usage quantity of that drug.

The financial transaction is completed after the HL7 ACK message is received, at which time the transaction is posted back to the database where the utilization records involved with that transaction are marked with an Export Date/Time.

HL7 Definitions

The Merge Healthcare AIMS system supports these segments for HL7 DFT messages:

Within each supported segment, the Merge Healthcare AIMS system can process and export these elements:




4. FT1 Financial Transaction


Segment Field Subfield HL7 Definition Comment

MSH 1 Field Separator |

MSH 2 Encoding Characters Literal "^~\&"

MSH 3 Sending Application Literal "MERGEAIMS"

30


MSH 4 Sending Facility Sending facility for multi-facility customers, or “Default” for single-facility customers

MSH 9 1 Message Type Literal "DFT"

MSH 9 2 Trigger Event Literal "P03"

MSH 10 Message Control ID [msg_control_id]

MSH 11 Processing ID Literal "P"

MSH 12 HL7 Version Literal "2.3"

MSH 15 Accept Ack Type Literal "AL"

MSH 16 Application Ack Type Literal "NE"



PID 3 1 Patient MRN [patient_mrn]

PID 5 1 Patient Last Name [patient_last_name]

PID 5 2 Patient First Name [patient_first_name]

PID 18 Patient Account Number [patient_account_number]



PV1 2 Patient Class [patient_class]

PV1 3 1 Patient Facility [use_location] -- OR Name

PV1 19 1 Patient Visit Number [visit_number]

Table 2-4: FT1 Definition


FT1 2 Transaction ID [transaction_id]

FT1 4 1 Use Date [use_date] -- Date/Time of use

FT1 5 Posting Date [posting_date]

FT1 6 Debit/Credit Indicator [debit_credit] -- "D" or "C" (Configurable)

FT1 7 1 Charge Code [charge_code] -- Hospital Charge Code



31


DFT^P03 Message Template

MSH|^~\&|MERGEAIMS|[sending_facility]|[target_app]|[target_facility]|[message_date_time]||DFT^P03|[msg_control_id]|P|2.3|||

AL|NE|USA|EVN|P03|[message_date_time]|PID|||[patient_mrn]^^^[patient_facility]||[patient_last_name]^[patient_first_name]^[patient_middle_name]|

||||||||||||[patient_account_number]||PV1||[patient_class]|[use_location]||||||||||||||||[visit_number]|FT1||[transaction_id]||[use_date]|[posting_date]|[debit_credit]|[charge_code]^[product_name]^^[product_id]|

N4[product_ndc]ML[amount_delivered]||[quantity]||||||[department_code]||||[staff_id]^[staff_lastname]^[staff_firstname]|||||[procedure_code]|

Charge Utilization Message Example

MSH|^~\&|MERGEAIMS|Default|DataGateSimulator|FDBMain|20100915120430||DFT^P03|20100915120427170|P|2.3|||AL|NE|USA|EVN|P03|20100915120430|PID|||MRNU07.420^^^||KOPTAN_07.420ÂSHTON^|||||||||||||ANU07.420||PV1||I|OR 01||||||||||||||||VN07.420|FT1||I0af36e13-a22d-46e1-bc6a-821c8853a644||20100820112327|20100915120430|CH|54354^Morphine 500mg / 500mL

NS^^N409998768098ML500^|||1||||||FDBMainPharm||||^^||||||

FT1 7 2 Product Name [product_name]

FT1 7 4 Product ID [product_id]

FT1 8 1 NDC Quantity N4[product_ndc]ML[amount_delivered]

FT1 10 7 Quantity [quantity] -- Billable Quantity

FT1 16 1 Department Code [department_code]

FT1 20 1 Staff ID [staff_id]

FT1 20 2 Staff Last Name [staff_lastname]

FT1 20 3 Staff First Name [staff_firstname]

FT1 25 1 Procedure Code [procedure_code]

Table 2-4: FT1 Definition (Continued)


32


Post Case - ORUThis interface is designed to provide information indicating various aspects of an anesthesia procedure. The outbound message is triggered upon close-of-case. Here is one of the benefits of having a Post Case interface:

● Destination system will be appraised of various case aspects immediately upon close of case.

Post Case Interface Functionality

The HL7 Post-Case Interface runs as a Windows service, and communicates with the system database via the AIMS system web service, over HTTPS. It polls the database for newly-closed anesthesia cases, and sends out an HL7 ORU R01 message for any cases closed since the previous polling interval (generally set at 1 minute).

At the close of an anesthesia case, the system parses out the case data sent to the server from the AIMS Anesthesia client machine in the OR where the case ran. The case data are parsed out and stored in the relational database (SQL Server). The final action of close-of-case processing is the triggering of the outbound Post-Case HL7 transaction. This is achieved via a database trigger populating a polling table.

Any open transactions will be found in this 'ClosedCasePolling' table. There will be one HL7 transaction per case. The Post-Case interface service will poll the database for any open transactions (which it has not yet processed). Cases will be processed in the order in which they were closed.

HL7 Definitions





3. OBR Observation Request Information

4. OBX Observation






MSH 5 Receiving Application DestApp

33


MSH 7 Message Date/Time [message_date_time]

MSH 9 1 Message Type Literal "ORU"

MSH 9 2 Trigger Event Literal "R01"



MSH 12 HL7 Version Literal "2.3.1"



MSH 17 Country Code Literal "USA"



PID 3 1 Patient MRN CX:5 = "AN"

MRN CX:5 = "MR"

Case number CX:5 = "CASE"

SS# CX:5 = "SS"



PID 5 3 Patient Middle Name [patient_middle_name]

PID 7 Patient Date of Birth [patient_DOB]

PID 8 Patient Sex [patient_sex]

PID 18 1 Patient Account Number [patient_account_number]

PID 19 Patient Social Sec Number [patient_SS]

Table 2-7: OBR Definition


OBR 3 Observation Identifier [filler_appt_id]

OBR 4 1 Universal Service ID Literal "5000.8"

OBR 4 2 Universal Service Text Literal "ANESTHESIA"

OBR 4 3 Name of Coding System Literal "AS4"



34


NOTE: If a particular event did not occur during the case, such as no PREOPSTART event ever happened, then the OBX segment which would ordinarily have represented that event will not be present in the HL7 message. Therefore, the SET ID of the OBX will not be a reliable means of locating a particular piece of information for parsing out. Instead, the code found in OBX:3.1, or OBX:3.2 must be used to locate which OBX instance contains the needed information from OBX:5

The default indicators are as follows:

● PRIMARYPROCEDURE = 1

● ANESTHESIATYPE = 2

● ASACLASS = 3

● PREOPSTART = 4

● INROOMSTART = 5

● ANESTHESIASTART = 6

● INCISIONSTART = 7

● INCISIONEND = 8

● INCISIONMINUTES = 9

● INROOMEND = 10

● ANESTHESIAEND = 11

● PACUEND = 12

The preceding codes can be reconfigured to match codes or descriptions in your system, but the meaning of the information they represent must be carefully preserved if such reconfiguration is considered.

Table 2-8: OBX Definition


OBX 1 Set ID [setid] -- Identifies Give Instance of OBX

OBX 2 Value Type HL7 Data Type found in OBX-5

OBX 3 1 Observation Identifier/ID Indicates which element of the case data this particular OBX contains.

OBX 3 2 Observation Identifier/Text Text version of the ID in OBX-3

OBX 5 1 Observation Value Actual Information: Date/Time, procedure type, etc.

OBX 11 Observation Result Status Literal "F"

35


ANESTHESIA TYPE: The anesthesia types used will be limited to those found in the system database. No mapping to other systems is currently available. Any desired mapping of anesthesia types must be done within the receiving system.

ORU^R01 Message Template

MSH|^~\&|MERGEAIMS||DestApp||[message_date_time]||ORU^R01|[msg_control_id]|P|2.3.1|||AL|NE|USA|

PID|1||[patient_SS]^^^^SSN~[patient_mrn]^^^^MR~[filler_appt_id]^^^^CASE~[patient_account]^^^ÂN||[patient_last_name]^[patient_first_name]^[patient_middle_name]||[patient_DOB]|[patient_sex]||||||||||[patient_account]^^^ÂN|[patient_SS]|

OBR|1||[filler_appt_id]|5000.8ÂNESTHESIAÂS4|

OBX|[setid]|CE|1^PRIMARYPROCEDURE^99PSD||^[value]^99PS||||||F|

OBX|[setid]|CE|2ÂNESTHESIATYPE^99PSD||[value_id]^[value]^99DS||||||F|

OBX|[setid]|CE|3ÂSACLASS^99PSD||[value_id]^[value]^99DS||||||F|

OBX|[setid]|TS|4^PREOPSTART^99PSD||[value]||||||F|

OBX|[setid]|TS|5ÎNROOMSTART^99PSD||[value]||||||F|

OBX|[setid]|TS|6ÂNESTHESIASTARTTIME^99PSD||[value]||||||F|

OBX|[setid]|TS|7ÎNCISIONSTART^99PSD||[value]||||||F|

OBX|[setid]|TS|8ÎNCISIONEND^99PSD||[value]||||||F|

OBX|[setid]|NM|9ÎNCISIONMINUTES^99PSD||[value]|Min|||||F|

OBX|[setid]|TS|10ÎNROOMEND^99PSD||[value]||||||F|

OBX|[setid]|TS|11ÂNESTHESIASTOPTIME^99PSD||[value]||||||F|

OBX|[setid]|TS|12^PACUEND^99PSD||[value]||||||F|

36


Post-Case Message Example

MSH|^~\&|MERGEAIMS||DestApp||20050628141450||ORU^R01|20050628444|P|2.3.1|||AL|NE|USA|

PID|1||444-44-4444^^^^SSN~FMRN100^^^^MR~444^^^^CASE~FACCT100^^^ÂN||LASTNAME^FIRSTNAME^MID

OBR|1||444|5000.8ÂNESTHESIAÂS4|

OBX|1|CE|1^PRIMARYPROCEDURE^99PSD|1|^PROC_ID3^99PS||||||F|

OBX|2|CE|2ÂNESTHESIATYPE^99PSD|1|EPIGENÊpidural and General^99DS||||||F|

OBX|3|CE|3ÂSACLASS^99PSD|1|ÎV^99DS||||||F|

OBX|4|TS|6ÂNESTHESIASTARTTIME^99PSD|1|20050628135606||||||F|

OBX|5|TS|11ÂNESTHESIASTOPTIME^99PSD|1|20050628135915||||||F|

OBX|6|TS|7ÎNCISIONSTART^99PSD|1|20050628135755||||||F|

OBX|7|TS|8ÎNCISIONEND^99PSD|1|20050628135757||||||F|

OBX|8|TS|5ÎNROOMSTART^99PSD|1|20050628135719||||||F|

OBX|9|TS|10ÎNROOMEND^99PSD|1|20050628135811||||||F|

OBX|10|TS|4^PREOPSTART^99PSD|1|20050628135610||||||F|

OBX|11|TS|12^PACUEND^99PSD|1|20050628135922||||||F|

OBX|12|NM|9ÎNCISIONMINUTES^99PSD|1|1|Min|||||F|

37


Clinical Data - OutboundThis interface is designed to share discrete clinical information documented in the PreAnesthesia Evaluation (PAE) and in the anesthesia record. The outbound messages are triggered differently depending on the data:

● Allergies can be documented in either the PAE or the Anesthesia record, and are sent when saved (real-time).

● Timed events (Patient In Room, Procedure Start, etc) are documented in the anesthesia record, and are sent when saved (real-time). This supports a shared intraoperative workflow between anesthesia and nursing.

● Other data documented in the PAE are sent when the PAE is signed and/or Finalized.

● Other data documented in the anesthesia record are sent when the record is signed and closed, including closing an appended case.

The clinical data interface is intended to support shared workflows and shared discrete data.

● Combined with the inbound clinical data interface, duplicate data entry is minimized (ie, data entered by Nursing within the Nursing system becomes available in the Anesthesia system, and data entered by Anesthesia becomes available within the Nursing system).

● Patient safety is enhanced by sharing codified allergy and medication lists.

Clinical Data Interface Functionality

The HL7 Clinical Data Interface runs as a Windows service, and communicates with the system database via the AIMS system web service, over HTTPS. It polls the database for updated records, and sends out the appropriate HL7 messages for any data since the previous polling interval (generally set at 1 minute).

Any open transactions will be found in the 'Outbound Clinical Data Polling' table. There may be multiple transactions per case (per patient). The Outbound interface service will poll the database for any open transactions (which it has not yet processed).

HL7 Definitions


1. MSH Message Header All

2. PID Patient Identification All

3. PV1 Patient Visit All

38



4. OBR Observation Request Information NPO Status

Medical history conditions

Family anesthesia history

Surgical history

PreOp vital signs

PostOp (PACU) vital signs

Timed events

Fluid outputs & balance

Anesthesia type & ASA

5. OBX Observation

6. AL1 or IAM

Patient Allergy and Adverse Reaction information

Allergies

6. DG1 Diagnosis ICD-9 coding

7. PR1 Procedures Surgical procedures & times

CPT coding

8. ORC Common Order Medications delivered

Infusions delivered

9. RXE and RXR

Pharmacy Encoded Order

Pharmacy Route

Medications delivered

Infusions delivered

10. RXC Pharmacy Component Order Infusions delivered (base solution and additives)

11. NTE Notes and Comments Various






MSH 4 Sending Facility Sending facility for multi- facility customers, or "Default" for single-facility customers

MSH 5 Receiving Application "CLINICALHIS" or other literal value

MSH 7 Message Date/Time [message_date_time]

39


MSH 9 1 Message Type Configured literal (such as "ORU"), or for Allergies "ADT"

MSH 9 2 Trigger Event Configured literal (such as "R01") or for Allergies: "A08" or "A60"



MSH 12 HL7 Version Literal "2.4"



MSH 17 Country Code Literal "USA"



PID 3 1 Patient MRN Account Number CX:5 = "AN"

MRN CX:5 = "MR"

Case number CX:5 = "CASE"

SS# CX:5 = "SS"

Note: Can also be configured similar to Charge Interface



PID 5 3 Patient Middle Name [patient_middle_name]

PID 7 Patient Date of Birth [patient_DOB]

PID 8 Patient Sex [patient_sex]

PID 18 1 Patient Account Number [patient_account_number]

PID 19 Patient Social Sec Number [patient_SS]

Table 2-9: MSH Definition (Continued)


40




PV1 2 Patient Class [patient_class]

PV1 19 1 Patient Visit Number [visit_number]

Table 2-12: OBR Definition (optionally included in any messages using OBX segments)


OBR 3 Observation Identifier [filler_appt_id]

OBR 4 1 Universal Service ID Literal "5000.8" or other configured value

OBR 4 2 Universal Service Text Literal "ANESTHESIA" or other configured value

OBR 4 3 Name of Coding System Literal "AS4" or other configured value

Table 2-13: OBX Definition (message structure defined here. See table below for values specific to each type of data)


OBX 1 Set ID [setid]

OBX 2 Value Type [value_type]

OBX 3 1 Observation Identifier/ID [observation_ID]

OBX 3 2 Observation Identifier/Text [observation_text]

OBX 3 3 Observation Coding System

[observation_name_of_coding_system]

OBX 4 Observation Sub-ID [observation_sub_id]

OBX 5 Observation Value [value]

OBX 6 Units [value_units]

OBX 7 Reference Range [references_range]

OBX 8 Abnormal Flags [abnormal_flags]

OBX 11 Observation Result Status [observation_result_status]

OBX 14 Observation Date-Time [observation_date_time]

OBX 15 1 Producer's ID Identifier [source_id]

OBX 15 3 Producer's ID Coding System

[source]

OBX 16 Responsible Observer XCN structure as defined below [responsible_observer]

41


The following tables show how the OBX segments may be populated with the data applicable to each message type.

Table 2-14: NTE Definition (comments)


NTE 1 Set ID [setid]

NTE 3 Comment [comment]

Table 2-15: XCN Definition (staff identifier data structure)

Sequence HL7 Definition Comment

1 ID number Interface ID

2 Family name Last name

3 Given name First name

4 Second and further given names or initials

Middle name

5 Suffix (e.g., JR or III) Suffix

6 Prefix (e.g., DR) Prefix

7 Degree (e.g., MD) Credentials

Table 2-16: NPO Status - a set of 2 OBX segments; the first is always included, and the second is included only if the date-time is documented.

Field Content

[setid] 1 for Since Midnight checkbox

2 for NPO date-time

[value_type] Set ID 1: CE

Set ID 2: TS

[observation_ID] Set ID 1: NPOSINCEMIDNIGHT or other mapped value

Set ID 2: NPO or other mapped value

[observation_text] Set ID 1: NPO since midnight (checkbox)

Set ID 2: NPO since the specified time

[observation_name_of_coding_system] Literal "MergeAIMS"

[observation_sub_id] <null>

[value] Set ID 1: True or False

Set ID 2: NPO date-time

[value_units] <null>

[references_range] <null>

42


[abnormal_flags] <null>

[observation_result_status] Literal "F"

[observation_date_time] Set ID 1: Last Saved date-time

Set ID 2: Patient's NPO date-time

[source_id] <null>

[source] <null>

[responsible_observer] <null>

NTE comment segment Included following each/both segments, when comment is present

Table 2-17: Medical history conditions - zero to many OBX segments, one per each condition in the PAE. Note that deleted (= inactive) are also included.

Field Content

[setid] Incremented counter

[value_type] CE

[observation_ID] Condition mapped identifier; will be <null> is not mapped

[observation_text] Print Description



[value] "True" if active

"False" if inactive or deleted




[observation_result_status] "F" if active

"D" if inactive or deleted

[observation_date_time] Last Updated date-time

[source_id] <null>

[source] <null>

Table 2-16: NPO Status - a set of 2 OBX segments; the first is always included, and the second is included only if the date-time is documented. (Continued)

Field Content

43


[responsible_observer] XCN structure of saved-by staff, or Username if staff not available (eg, data received from external system)

NTE comment segment Included when a comment is present

Table 2-18: Family anesthesia history - one OBX segment

Field Content

[setid] 1

[value_type] CE

[observation_ID] Mapped identifier

[observation_text] One of four possible values: "PROBLEMS", "NO PROBLEMS", "NO HISTORY", or "UNKNOWN"



[value] One of four possible values: "PROBLEMS", "NO PROBLEMS", "NO HISTORY", or "UNKNOWN"




[observation_result_status] "F" Final

[observation_date_time] Last Updated date-time

[source_id] <null>

[source] <null>



Table 2-19: Surgical history - zero to many OBX segments, one per surgical history row

Field Content


[value_type] TX

Table 2-17: Medical history conditions - zero to many OBX segments, one per each condition in the PAE. Note that deleted (= inactive) are also included.

Field Content

44


[observation_ID] Mapped identifier for Surgical History

[observation_text] Description of surgery



[value] Description of surgery


[references_range] Mapped identifier for anesthesia type, or SWKey if no mapping present.

[abnormal_flags] T or F from the "Perioperative complications?" checkbox

[observation_result_status] "F" Final

[observation_date_time] Date of surgery. If documented as year-only, will be sent as January 1st ("2002" = "20020101000000").

[source_id] <null> unless result was received from external system

[source] <null> unless result was received from external system



Table 2-20: PreOp and PostOp (PACU) vital signs - a collection of OBX segments, one per measurement

Field Content


[value_type] NM Numeric value except for:

BLOODPRESSURE = TX

TEMPERATUREMODE = TX

PATIENTONROOMAIR = CE

PATIENTONOXYGEN = CE

[observation_ID] Mapped ID such as PREOP_VITALS or POSTOP_VITALS

[observation_text] "PreOp Vital Signs" or "PACU Vital Signs"

Table 2-19: Surgical history - zero to many OBX segments, one per surgical history row

Field Content

45



[observation_sub_id] HEIGHT

WEIGHT

HEIGHT and WEIGHT are literal (not mapped). All others are "Mapped IDs corresponding to the following:"

SYSTOLIC

DIASTOLIC

BLOODPRESSURE

TEMPERATURE

TEMPERATUREMODE

PULSERATE

RESPIRATIONRATE

SPO2

PATIENTONROOMAIR

PATIENTONOXYGEN

OXYGENSETTING

[value] Numeric value except for:

BLOODPRESSURE = Systolic/Diastolic as a combined field "120/80"

TEMPERATUREMODE = string value "Oral"

PATIENTONROOMAIR = True or False

PATIENTONOXYGEN = True or False

Table 2-20: PreOp and PostOp (PACU) vital signs - a collection of OBX segments, one per measurement (Continued)

Field Content

46


[value_units] Configurable for HEIGHT

Configurable for WEIGHT

mmHg for SYSTOLIC

mmHg for DIASTOLIC

mmHg for BLOODPRESSURE

Configurable for TEMPERATURE

<null> for TEMPERATUREMODE

BPM for PULSERATE

BPM for RESPIRATIONRATE

% for SPO2

<null> for PATIENTONROOMAIR

<null> for PATIENTONOXYGEN

% or L/min for OXYGENSETTING



[observation_result_status] "F" (Final)

[observation_date_time] Date time of the collection of vitals (single value shared for all measurements)

[source_id] <null>

[source] <null>


NTE comment segment Included when a comment is present (single NTE after the collection of OBXs)

Table 2-21: Timed events - zero to many OBX segments, one per event

Field Content


[value_type] TS

[observation_ID] Mapped identifier; <null> if not mapped

[observation_text] Display name of event



Table 2-20: PreOp and PostOp (PACU) vital signs - a collection of OBX segments, one per measurement (Continued)

Field Content

47


[value] Date-time of event





[observation_date_time] Date-time of event

[source_id] <null>

[source] <null>


Table 2-22: Fluid outputs & balance - one to many OBX segments, one per output plus one for fluid balance

Field Content


[value_type] NM

[observation_ID] SWKey of output fluid

NETBALANCE for fluid balance

[observation_text] Display name of output fluid

"Net perioperative fluid balance"



[value] Numeric balance (sum of input infusions and fluids, minus sum of output fluids; can be negative)

[value_units] "mL"




[observation_date_time] <null>

[source_id] <null>

[source] <null>


Table 2-21: Timed events - zero to many OBX segments, one per event

Field Content

48


The patient's medication profile of Home and Current medications (documented in PAE; this is not the anesthesia-delivered medications) is sent in RDEÔ11 messages. The MSH, PID, and

Table 2-23: Anesthesia type & ASA - one to many OBX segments, one for ASA class plus one for each anesthesia type documented.

Field Content


[value_type] CE

[observation_ID] ASA

ATYP for primary anesthesia type

AATYP for additional types

[observation_text] "ASA Class"

"Anesthesia Type (Primary)"

"Additional Anesthesia Type"


[observation_sub_id] <null> for ASA

Mapped identifier for anesthesia type, or SWKey if no mapping present.

[value] ASA Physical Status description, typically roman numeral I through V or IE through VE where E indicates an emergency surgery

CE structure with mapped identifier, anesthesia type display name, and "MergeAIMS"





[observation_date_time] <null>

[source_id] <null>

[source] <null>


49


PV1 segments are described above. Each medication is sent in a separate message, with a single ORC, RXE, and RXR segment.

Table 2-24: Definition for Home/Current Medications


ORC 2 1 Placer Order Number Row ID from database (GUID)

ORC 5 1 Order Status "IP" (In Process)

ORC 9 1 Date/Time of Transaction Documentation date-time

ORC 10 1 Entered By XCN structure of saved-by staff, or Username if staff not available (eg, data received from external system)

ORC 21 1 Ordering Facility Name "DOCUSYS" if entered by Anesthesia; other value if data received from external system

ORC 21 3 Ordering Facility ID Numeric ID if entered by Anesthesia; other value if data received from external system



RXE 1 1-2 Quantity/Timing Frequency (split at first space " " character)

RXE 2 1 Give Code - Identifier Identifier (varies based on installed Drug Information Framework)

FDB = Drug Name ID

Multum = D Number

Micromedex = Generic Formulation Code

RXE 2 2 Give Code - Description Name of medication

RXE 2 3 Give Code - Identifier Type Varies based on installed Drug Information Framework:

FDB = "DNID"

Multum = "DNUM"

Micromedex = "GFC"

50


RXE 2 4 Give Code - Alternate Identifier

Identifier (varies based on installed Drug Information Framework)

FDB = Dispensable Drug ID

Multum = Synonym ID

Micromedex = <null> but may include the NDC if data received from external system

RXE 2 6 Give Code - Alternate Identifier Type

Varies based on installed Drug Information Framework:

FDB = "MEDID"

Multum = "SYN"

Micromedex = "NDC"

RXE 3 1 Give Amount Dose field (up to first space " " character)

Note: Not guaranteed numeric.

RXE 5 1 Give Units Dose field (after first space " " character)

RXE 7 1 Administration Instructions Comment

RXE 18 1 Date-Time of most recent refill or dose

Last Taken

Note: This comes from a text field, so it generally won't be a well-formatted date and may be null.



RXR 1 2 Route - text Route

Table 2-25: RXE Definition for Home/Current Medications (Continued)


51


The patient's medication profile of anesthesia-delivered medications is sent in an ORMÔ01 message. The MSH, PID, and PV1 segments are described above. Each delivery is sent in an ORC, RXE, and RXR segment group. Multiple deliveries are included in a single message.

Table 2-27: ORC Definition for Delivered Medications



ORC 5 1 Order Status "CM" = completed

ORC 7 1 Quantity/Timing "1" = a single delivery

ORC 9 1 Date/Time of Transaction Date-time of delivery

ORC 12 Ordering Provider XCN structure of staff

ORC 21 1 Ordering Facility Name Source system = "MergeAIMS"

ORC 21 3 Ordering Facility ID Source ID = Row ID from database (GUID)

Table 2-28: RXE Definition for Delivered Medications


RXE 2 1 Give Code - Identifier Charge Code as configured in AIMS Formulary

RXE 2 2 Give Code - Description Primary display name of medication

RXE 2 3 Give Code - Identifier Type "CHARGECODE"

RXE 2 4 Give Code - Alternate Identifier

Identifier (varies based on installed Drug Information Framework)

FDB = Routed Medication ID

Multum = Synonym ID

Micromedex = Generic Formulation Code

RXE 2 5 Give Code - Alternate Text Mapped Drug Name from Drug Information Framework, as configured in AIMS Formulary

52


RXE 2 6 Give Code - Alternate Identifier Type

Varies based on installed Drug Information Framework:

FDB = "RMID"

Multum = "SYN"

Micromedex = "GFC"

RXE 3 1 Give Amount Delivery amount

Note: Will be 0 for "By Each" medications.

RXE 5 1 Give Units Delivery units; typically a drug weight unit such as "mg"

RXE 7 1 Administration Instructions <null>


<null>

RXE 23 1 Give Rate Amount <null>

RXE 24 1 Give Rate Units <null>

RXE 25 1 Give Strength Alternate delivery amount. If a "By Each" type of medication, this is the quantity; otherwise this is the delivery volume.

RXE 26 1 Give Strength Units Alternate units; "Each" or "mL"

RXE 31 1 Supplementary Code - ID NDC number, as configured in AIMS Formulary

RXE 31 2 Supplementary Code - Text NDC Description as configured in AIMS Formulary

RXE 31 3 Supplementary Code - Identifier type

"NDC"

RXE 31 4 Supplementary Code - Alternate ID

Billing NDC, as configured in AIMS Formulary

RXE 31 5 Supplementary Code - Alternate Text

NDC Description as configured in AIMS Formulary

RXE 31 6 Supplementary Code - Alternate Identifier type

"BILLINGNDC"

Table 2-28: RXE Definition for Delivered Medications (Continued)


53


The patient's medication profile of anesthesia-delivered infusions (plain fluids and drug infusions) is sent in an ORMÔ01 message. The MSH, PID, and PV1 segments are described above. Each delivery is sent in an ORC, RXE, RXC (if additives present), and RXR segment group. Multiple deliveries are included in a single Message. For infusions documented by rate, each change of rate is treated as a separate delivery.

Table 2-29: RXR Definition for Delivered Medications


RXR 1 1 Route - ID Route of delivery SWKey

RXR 1 2 Route - text Route of delivery name

Table 2-30: ORC Definition for Delivered Infusions



ORC 5 1 Order Status "CM" = completed

ORC 7 All Quantity/Timing TQ structure, defined below

ORC 9 1 Date/Time of Transaction Date-time of delivery, or end time if rate-based.

ORC 12 Ordering Provider XCN structure of staff

ORC 21 1 Ordering Facility Name Source system = "MergeAIMS"

ORC 21 3 Ordering Facility ID Source ID = Row ID from database (GUID)

Table 2-31: RXE Definition for Delivered Infusions


RXE 2 1-6 Give Code If the infusion is a plain fluid, then RXE-2 (subfields 1-6) is similar to medication delivery, above.

If the infusion includes drug additives, then RXE-2 is <null> and the RXC segment contains the detailed infusion definition.

RXE 3 1 Give Amount Delivery volume

RXE 5 1 Give Units Volume units, "mL"

RXE 7 1 Administration Instructions Infusion final disposition, such as "Completed" or "Transferred"

54



<null>

RXE 23 1 Give Rate Amount <null> if documented as a volume;

Rate value if documented as a rate

RXE 24 1 Give Rate Units <null> if documented as a volume;

"mL/hr" if documented as a rate

RXE 25 1 Give Strength <null>

RXE 26 1 Give Strength Units <null>

RXE 31 1 Supplementary Code - ID NDC number, as configured in AIMS Formulary (for infusion, not additive)

RXE 31 2 Supplementary Code - Text NDC Description as configured in AIMS Formulary

RXE 31 3 Supplementary Code - Identifier type

"NDC"

RXE 31 4 Supplementary Code - Alternate ID

Billing NDC, as configured in AIMS Formulary

RXE 31 5 Supplementary Code - Alternate Text

NDC Description as configured in AIMS Formulary

RXE 31 6 Supplementary Code - Alternate Identifier type

"BILLINGNDC"

Table 2-32: RXC Definition for Delivered Infusions - repeated for base solution and additive(s)


RXC 1 1 Rx Component Type "B" for base solution;

"A" for additive(s)

RXC 2 1-6 Component Code Component (base solution or additive) identifiers, similar to RXE-2 for medication deliveries

Table 2-31: RXE Definition for Delivered Infusions (Continued)


55


RXC 3 1 Component Amount Infusion initial volume for base solution (bag volume);

Additive initial amount (amount of additive in bag)

RXC 4 1 Component Units Volume units, "mL" for base solution

Additive units, typically a drug weight unit such as "mg"

RXC 5 1 Component Strength <null> for base solution;

Original concentration of additive (before it was diluted into infusion)

RXC 6 1 Component Strength Units <null> for base solution;

Original concentration units for additive

RXC 7 1 Supplementary Code NDC information for component (base solution or additive), similar to RXE-31

Table 2-33: RXR Definition for Delivered Infusions


RXR 1 1 Route - ID Route of delivery SWKey

RXR 1 2 Route - text Route of delivery name

Table 2-32: RXC Definition for Delivered Infusions - repeated for base solution and additive(s)


Table 2-34: TQ Definition (Timing/Quantity data structure for infusions)


1 Quantity "1" one delivery

2 Interval <null> if documented as a volume

"C" if documented as a rate

3 Duration <null> if documented as a volume

"M" and the duration in minutes if documented as a rate (ex: "M60")

56


Diagnosis codes can be documented in the PAE and also in AIMS Anesthesia. Procedure coding can only be documented in AIMS Anesthesia. Coding data are sent when the PAE is signed and when the Anesthesia record is signed. Coding data consists of 1) zero to many DG1 diagnosis segments, 2) zero to many PR1 surgical procedure segments, and 3) zero to many PR1 procedure coding segments, which include both surgeon-performed and personally-performed procedures.

4 Start date-time <null> if documented as a volume

Rate start time if documented as a rate

5 End date-time Delivery time if documented as a volume

Rate end time if documented as a rate

Table 2-34: TQ Definition (Timing/Quantity data structure for infusions)


Table 2-35: DG1 Definition for Diagnosis Code(s)


DG1 1 Set ID Incremented counter

DG1 3 1 Diagnosis Code/ Identifier Diagnosis code (number)

DG1 3 2 Diagnosis Code/ Text Diagnosis description

DG1 3 3 Diagnosis Code/ Identifier Type

"I9" = ICD-9

DG1 5 Diagnosis Date/Time PAE: when the PAE was signed

AIMS Anesthesia: when the code was documented

DG1 6 Diagnosis Type "W" = Working

DG1 15 Diagnosis Priority "0" = not ranked

DG1 16 Diagnosing Clinician XCN structure of staff who signed the anesthesia record; if record not yet signed (PAE signing trigger event) then this will be the PAE signer.

57


DG1 17 Diagnosis Classification "D" = Diagnosis

DG1 19 Attestation Date/Time PAE: when the PAE was signed

AIMS Anesthesia: when the record was signed

Note: Associated with DG1-16. Either the anesthesia record signer/signed time, or if that's not signed yet then it's the PAE signer/signed time.

Table 2-36: PR1 Definition for Procedure Code(s) personally performed by Anesthesia staff


PR1 1 Set ID Incremented counter

PR1 3 1 Procedure Code/ Identifier Procedure code (number)

PR1 3 2 Procedure Code/ Text Procedure description

PR1 3 3 Procedure Code/ Identifier Type

"C4" = CPT-4

PR1 5 Procedure Date/Time When the code was documented

PR1 6 Procedure Functional Type "I" Personally performed procedures (codes for IV, catheter, etc)

PR1 7 Procedure Minutes <null>

PR1 8 Anesthesiologist <null>

PR1 9 Anesthesia Code <null>

PR1 10 Anesthesia Minutes <null>

PR1 11 Surgeon <null>

PR1 12 Procedure Practitioner XCN structure of Linked staff member, if documented

PR1 14 Procedure Priority <null> Procedure codes are not ranked

PR1 15 Associated Diagnosis Code <null>

PR1 16 Procedure Code Modifier <null>

Table 2-35: DG1 Definition for Diagnosis Code(s) (Continued)


58


Table 2-37: PR1 Definition for Procedure Code(s) not personally performed



PR1 3 1 Procedure Code/ Identifier Procedure code (number)



"C4" = CPT-4

PR1 5 Procedure Date/Time Individual procedure start time if code linked to actual procedure, otherwise the overall Incision Start Time

PR1 6 Procedure Functional Type "P" Procedure for Treatment (codes for the surgery)

PR1 7 Procedure Minutes Individual procedure time if code linked to actual procedure, otherwise the overall Incision Time. This is a duration (number of minutes, can be a decimal value) not a timestamp.

PR1 8 Anesthesiologist XCN structure of Anesthesia staff who signed the record

PR1 9 1 Anesthesia Code/ Identifier Anesthesia crosswalk code (number)

PR1 9 2 Anesthesia Code/ Text Anesthesia crosswalk description

PR1 9 3 Anesthesia Code/ Identifier Type

"XWALK" Crosswalk

PR1 10 Anesthesia Minutes Anesthesia Time duration (total for case)

PR1 11 Surgeon XCN structure of Surgeon linked to code, if documented; otherwise primary surgeon for the case

PR1 12 Procedure Practitioner Same as PR1-11 Surgeon

PR1 14 Procedure Priority <null> Procedure codes are not ranked

59


The anesthesia record may cover a single surgery, or can document multiple "actual" surgical procedures (there can also be multiple scheduled procedures, but those are not relevant here). Each surgical procedure will be sent as a PR1 segment within an ORU^R01 message.

PR1 15 1 Associated Diagnosis Code/ Identifier

Linked diagnosis code, if documented (either linked to same actual procedure as this CPT code, or the first "linked code" among the diagnosis codes)

PR1-15 is <null> if none found.

PR1 15 2 Associated Diagnosis Code/ Description

Linked diagnosis description

PR1 15 3 Associated Diagnosis Code/ Identifier Type

"I9" ICD-9

PR1 16 (can repeat)

1 Procedure Code Modifier/ Identifier

Modifier code(s)

PR1 16 2 Procedure Code Modifier/ Description

Modifier description(s)

PR1 16 3 Procedure Code Modifier/ Identifier type

"CPTM" CPT Modifier

Table 2-37: PR1 Definition for Procedure Code(s) not personally performed (Continued)


Table 2-38: PR1 Definition for Surgical Procedure(s)



PR1 3 1 Procedure Code/ Identifier Hospital scheduling code if scheduled

<null> if added by anesthesia user



"ScheduledProcedure" if scheduled

"MergeAIMS" if added by anesthesia user

PR1 3 4 Procedure Code/ Alt Identifier

CPT code, if linked to actual procedure (otherwise <null> for subfields 4-6)

PR1 3 5 Procedure Code/ Alt Text CPT description

60


Allergy messages are sent whenever the AIMS user updates the patient allergy profile. Either of two message styles are supported: an ADTÂ08 with AL1 segments, or an ADTÂ60 with IAM segments.

PR1 3 6 Procedure Code/ Alt Identifier Type

"C4" = CPT-4

PR1 5 Procedure Date/Time Procedure Start time. Same as Incision Start time if only one procedure.

PR1 6 Procedure Functional Type "P" = Procedure

PR1 7 Procedure Minutes Procedure duration in minutes. Same as Incision Time duration if only one procedure.

PR1 8 Anesthesiologist <null>

PR1 9 Anesthesia Code <null>

PR1 10 Anesthesia Minutes <null>

PR1 11 Surgeon XCN structure of primary surgeon

PR1 12 Procedure Practitioner <null>

PR1 14 Procedure Priority Procedure rank (1, 2, etc)

PR1 15 1 Associated Diagnosis Code/ Identifier

Diagnosis code, if linked to actual procedure (otherwise <null>)

PR1 15 2 Associated Diagnosis Code/ Description

Linked diagnosis description

PR1 15 3 Associated Diagnosis Code/ Identifier Type

"I9" ICD-9

PR1 16 (can repeat)

1 Procedure Code Modifier/ Identifier

Modifier code(s, if any) for CPT in PR1-3.4

PR1 16 2 Procedure Code Modifier/ Description

Modifier description(s)

PR1 16 3 Procedure Code Modifier/ Identifier type

"CPTM" CPT Modifier

Table 2-38: PR1 Definition for Surgical Procedure(s) (Continued)


61


For the AL1 style, only active (non-deleted) allergies are included. For the IAM style, both active and deleted allergies are included.

Table 2-39: AL1 Definition


AL1 1 1 Set ID Incremented counter

AL1 2 1 Allergen Type Code Configured value such as "DA" (Drug Allergy)

AL1 3 1 Allergen Code/ID Substance identifier (ID from Drug Information Framework)

"-1" if No Known Drug Allergies

AL1 3 2 Allergen Code/Text Substance description

"NKDA" if No Known Drug Allergies

AL1 3 3 Allergen Code/Type Configured value, as appropriate based on Drug Information Framework

AL1 3 5 Allergen Code/ Alternate Text

Comment (free text)

AL1 5 1, can repeat

Allergic Reaction Reaction(s)

AL1 7 1 Sensitivity Code "IN" or other configured value if allergy is marked as an Intolerance

"AL" for allergies



IAM 1 1 Set ID Incremented counter

IAM 2 1 Allergen Type Code Configured value such as "DA" (Drug Allergy)

IAM 3 1 Allergen Code/ID Substance identifier (ID from Drug Information Framework)

"-1" if No Known Drug Allergies

IAM 3 2 Allergen Code/Text Substance description

"NKDA" if No Known Drug Allergies

62


IAM 3 3 Allergen Code/Type Configured value, as appropriate based on Drug Information Framework

IAM 3 5 Allergen Code/ Alternate Text

Comment (free text)

IAM 5 1 (can repeat)

Allergic Reaction Reaction(s)

IAM 6 1 Allergy Action "U" Update for active allergies

"D" Delete for inactive allergies

IAM 7 1 Allergy Unique Identifier Source ID from external system if originally documented externally

Numeric identifier if documented by AIMS user

IAM 7 2 Allergy Source System Source Name from external system if originally documented externally

"DOCUSYS" if documented by AIMS user

IAM 9 1 Sensitivity to Causative Agent code

"IN" or other configured value if allergy is marked as an Intolerance

"AL" for allergies

IAM 17 1 Allergy Clinical Status Code C Confirmed or verified

D Doubt raised

E Erroneous

I Confirmed but inactive

P Pending

S Suspect

U Unconfirmed

Table 2-40: IAM Definition (Continued)


63


Clinical Data Message Template

Template for NPO Status Message

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||ADTÂ08|[msg_control_id]|P|2.4|||AL|NE|USA|

EVN||[message_date_time]|

PID|1||[patient_SS]^^^^SSN~[patient_mrn]^^^[patient_facility]^MR~[filler_appt_id]^^^[patient_facility]^CASE~[patient_account_number]^^^[patient_facility]ÂN||[patient_last_name]^[patient_first_name]^[patient_middle_name]||[patient_DOB]|[patient_sex]||||||||||[patient_account_number]^^^[patient_facility]ÂN|[patient_SS]|

PV1||[patient_class]|||||||||||||||||[visit_number]|


OBX|[setid]|[value_type]|[observation_ID]^[observation_text]^[observation_name_of_coding_system]|[observation_sub_id]|[value]|[value_units]|[references_range]|[abnormal_flags]|||[observation_result_status]|||[observation_date_time]|[source_id]^^[source]|[responsible_observer]||

NTE

Template for Medical History Conditions Message

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||ORU^R01|[msg_control_id]|P|2.4|||AL|NE|USA|





NTE

Template for Family Anesthesia History Message



64





NTE

Template for Surgical History Message






NTE

Template for Vital Signs Messages






NTE

Template for Timed Events Message


65






Template for Fluid Output & Balance Message






Template for Anesthesia Types and ASA Class Message






Template for Home/Current Medications Messages

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||RDEÔ11|[msg_control_id]|P|2.4|||AL|NE|USA|

66




ORC||[order_identifier]|||[order_status]||||[order_date_time]|[user_name]|||||||||||[source]^^[source_id]|

RXE|[frequency_quantity]^[frequency_interval]|[medication_identifier]^[medication_description]^[medication_identifier_type]^[medication_alt_identifier]^^[medication_alt_identifier_type]|[dose_amount]||[dose_units]||[comment]|||||||||||[last_taken]|

RXR|^[route_of_administration]|

Template for Delivered Medications Message

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||ORMÔ01|[msg_control_id]|P|2.4|||AL|NE|USA|



ORC||[order_identifier]|||[order_status]||[quantity_timing]||[order_date_time]|[user_name]||[ordering_provider]|||||||||[source]^^[source_id]|

RXE||[medication_identifier]|[dose_amount]||[dose_units]||[comment]|||||||||||[last_taken]|||||[rate_amount]|[rate_units]|[alt_dose_amount]|[alt_dose_units]|||||[supplementary_code]|

RXR|[route_of_administration_identifier]^[route_of_administration]|

Template for Delivered Infusions Message

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||ORMÔ01|[msg_control_id]|P|2.4|||AL|NE|USA|



ORC||[order_identifier]|||[order_status]||[quantity_timing]||[order_date_time]|[user_name]||[ordering_provider]|||||||||[source]^^[source_id]|

RXE||[medication_identifier]|[dose_amount]||[dose_units]||[comment]|||||||||||[last_taken]|||||[rate_amount]|[rate_units]|[alt_dose_amount]|[alt_dose_units]|||||[supplementary_code]|

RXR|[route_of_administration_identifier]^[route_of_administration]|

RXC|[component_type]|[component_code]|[component_amount]|[component_units]|[component_strength]|[component_strength_units]|[supplementary_code]|

67


Template for Coding Message




DG1|[setid]||[diagnosis_code]||[diagnosis_date_time]|[diagnosis_type]|||||||||[diagnosis_priority]|[diagnosing_clinician]|[diagnosis_classification]||[attestation_date]|

PR1|[setid]||[procedure_code]||[procedure_date_time]|[procedure_type]|[procedure_minutes]|[anesthesiologist]|[anesthesia_code]|[anesthesia_minutes]|[surgeon]|[procedure_practitioner]||[procedure_priority]|[associated_diagnosis_code]|[procedure_code_modifier]|

Template for Surgical Procedures Message




PR1|[setid]||[procedure_code]||[procedure_date_time]|[procedure_type]|[procedure_minutes]|[anesthesiologist]|[anesthesia_code]|[anesthesia_minutes]|[surgeon]|[procedure_practitioner]||[procedure_priority]|[associated_diagnosis_code]|[procedure_code_modifier]|

Template for Allergy Message (AL1)

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||[msg_type]|[msg_control_id]|P|2.4|||AL|NE|USA|




AL1|[setid]|[allergy_category]|[allergen_id]^[allergen_description]^[allergen_type]^^[allergen_comment]||[allergy_reaction]||[allergy_sensitivity_code]

68


Template for Allergy Message (A60-IAM)

MSH|^~\&|MERGEAIMS|[sending_facility]|CLINICALHIS|[patient_facility]|[message_date_time]||[msg_type]|[msg_control_id]|P|2.4|||AL|NE|USA|




IAM|[setid]|[allergy_category]|[allergen_id]^[allergen_description]^[allergen_type]^^[allergen_comment]||[allergy_reaction]|[allergy_action]|[allergy_source_id]^[allergy_source]||[allergy_sensitivity_code]||||||||[allergy_status]

Clinical Data Message Example

Sample NPO Status Message

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012073639||ADTÂ08|20121012073638436|P|2.4|||AL|NE|USA|

EVN||20121012073639|

PID|1||111111111^^^^SSN~MRN01.93^^^FAC1^MR~FA01.93^^^FAC1^CASE~AN01.93^^^FAC1ÂN||LONGERÂMY^J||19710809000000|F||||||||||AN01.93^^^FAC1ÂN|111111111|

PV1||O|||||||||||||||||VN01.93|

OBR|1||FA01.93|5000.8ÂNESTHESIAÂS4|

OBX|1|CE|NPOSINCEMIDNIGHT^NPO since midnight (checkbox)^MergeAIMS||True||||||F|||20121011145625|^^|||

NTE|1||Had a snack at 8pm

OBX|2|TS|NPO^NPO since the specified time^MergeAIMS||20121010200000||||||F|||20121010200000|^^|||

NTE|1||Had a snack at 8pm

?

Sample Medical History Conditions Message

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012073639||ORU^R01|20121012073638045|P|2.4|||AL|NE|USA|


PV1||O|||||||||||||||||VN01.93|

69



OBX|1|CE|SMOKER^Current Smoker^MergeAIMS||True||||||F|||20121011110000|^^|BettySmith||

OBX|2|CE|DIABETES^Diabetes^MergeAIMS||True||||||F|||20121011110000|^^|BettySmith||

OBX|3|CE|^Patient’s usual blood pressure: ^MergeAIMS||True||||||F|||20121011145900|^^|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

NTE|1||180/120

OBX|4|CE|SMOKINGHX^Past history of smoking^MergeAIMS||True||||||F|||20121011110000|^^|BettySmith||

NTE|1||Since age 17.

OBX|5|CE|^Hypertension^MergeAIMS||True||||||F|||20121011145900|^^|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

OBX|6|CE|^Steroid use^MergeAIMS||False||||||D|||20121011145400|^^|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

OBX|7|CE|DIABETESTYPEIIÂdult-onset (Type II)^MergeAIMS||True||||||F|||20121011110000|^^|BettySmith||

NTE|1||Adult Onset at age 40.

OBX|8|CE|^Hyperparathyroidism^MergeAIMS||False||||||D|||20121011145400|^^|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

OBX|9|CE|HYPERTENSIONMALIGNANT^Malignant^MergeAIMS||True||||||F|||20121011110000|^^|BettySmith||

?

Sample Family Anesthesia History Message



PV1||O|||||||||||||||||VN01.93|


OBX|1|CE|FAMHXPROBLEMS^PROBLEMS^MergeAIMS||PROBLEMS||||||F|||20121011145322|^^|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

NTE|1||Mother had difficult airway and postop N&V.

?

Sample Surgical History Message


70



PV1||O|||||||||||||||||VN01.93|


OBX|1|TX|SURG_HXÂCL Repair^MergeAIMS||ACL Repair||MAC|T|||F|||20110412000000|31^^MEDITECH|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

NTE|1||Right knee

OBX|2|TX|SURG_HX^Cataract Removal^MergeAIMS||Cataract Removal||GENERAL_MASK|F|||F|||20090222000000|32^^MEDITECH|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||

NTE|1||Both eyes.

?

Sample Vital Signs Messages (PreOp and PostOp)



PV1||O|||||||||||||||||VN01.93|


OBX|1|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|HEIGHT|68|IN|||||F|||20121011145624|^^|||

OBX|2|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|WEIGHT|125|LB|||||F|||20121011145624|^^|||

OBX|3|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|SYSTOLIC|150|mmHg|||||F|||20121011145624|^^|||

OBX|4|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|DIASTOLIC|95|mmHg|||||F|||20121011145624|^^|||

OBX|5|TX|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|BLOODPRESSURE|150/95|mmHg|||||F|||20121011145624|^^|||

OBX|6|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|TEMPERATURE|98.6|F|||||F|||20121011145624|^^|||

OBX|7|TX|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|TEMPERATUREMODE|Oral||||||F|||20121011145624|^^|||

OBX|8|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|PULSERATE|62|BPM|||||F|||20121011145624|^^|||

OBX|9|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|RESPRATE|16|BPM|||||F|||20121011145624|^^|||

OBX|10|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|SPO2|99|%|||||F|||20121011145624|^^|||

71


OBX|11|CE|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|ROOMAIR|False||||||F|||20121011145624|^^|||

OBX|12|CE|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|ONOXYGEN|True||||||F|||20121011145624|^^|||

OBX|13|NM|PREOP_VITALS^PreOp Vital Signs^MergeAIMS|OXYGENSETTING|2|L/Min|||||F|||20121011145624|^^|||

NTE|1||Taken in POHA.

?


PID|1||111-11-1111^^^^SSN~MRN01.93^^^FAC1^MR~FA01.93^^^FAC1^CASE~AN01.93^^^FAC1ÂN||LONGERÂMY^J||19810809000000|F||||||||||AN01.93^^^FAC1ÂN|111-11-1111|

PV1||O|||||||||||||||||VN01.93|


OBX|1|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|HEIGHT|68|IN|||||F|||20121012110200|^^|||

OBX|2|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|WEIGHT|125|LB|||||F|||20121012110200|^^|||

OBX|3|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|SYSTOLIC|188|mmHg|||||F|||20121012110200|^^|||

OBX|4|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|DIASTOLIC|121|mmHg|||||F|||20121012110200|^^|||

OBX|5|TX|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|BLOODPRESSURE|188/121|mmHg|||||F|||20121012110200|^^|||

OBX|6|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|TEMPERATURE|99.2|F|||||F|||20121012110200|^^|||

OBX|7|TX|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|TEMPERATUREMODE|||||||F|||20121012110200|^^|||

OBX|8|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|PULSERATE|55|BPM|||||F|||20121012110200|^^|||

OBX|9|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|RESPRATE|15|BPM|||||F|||20121012110200|^^|||

OBX|10|NM|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|SPO2|98|%|||||F|||20121012110200|^^|||

OBX|11|CE|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|ROOMAIR|False||||||F|||20121012110200|^^|||

OBX|12|CE|POSTOP_VITALS^PACU Vital Signs^MergeAIMS|ONOXYGEN|False||||||F|||20121012110200|^^|||

NTE|1||taken on admit to PACU

?

72


Sample Timed Events Message



PV1||O|||||||||||||||||VN01.93|


OBX|1|TS|OR.INÎn Room Time^MergeAIMS||20121012095551||||||F|||20121012095551|^^|||

OBX|2|TS|Ânesthesia Start Time^MergeAIMS||20121012095551||||||F|||20121012095551|^^|||

OBX|3|TS|^%STAFF% - Doing Case^MergeAIMS||20121012095551||||||F|||20121012095551|^^|||

OBX|4|TS|^%STAFF% - Medical Direction/Supervision^MergeAIMS||20121012095551||||||F|||20121012095551|^^|||

OBX|5|TS|^Monitoring Begun^MergeAIMS||20121012095552||||||F|||20121012095552|^^|||

OBX|6|TS|PR.START^Surgery Begun^MergeAIMS||20121012095600||||||F|||20121012095600|^^|||

OBX|7|TS|^Prep Finished^MergeAIMS||20121012095600||||||F|||20121012095600|^^|||

OBX|8|TS|Înduction Begun^MergeAIMS||20121012095600||||||F|||20121012095600|^^|||

OBX|9|TS|Înduction Finished^MergeAIMS||20121012095636||||||F|||20121012095636|^^|||

OBX|10|TS|^Prep Begun^MergeAIMS||20121012095636||||||F|||20121012095636|^^|||

OBX|11|TS|PR.STOP^Surgery Finished^MergeAIMS||20121012104432||||||F|||20121012104432|^^|||

OBX|12|TS|^Dressing On^MergeAIMS||20121012104442||||||F|||20121012104442|^^|||

OBX|13|TS|Êmergence Finished^MergeAIMS||20121012104443||||||F|||20121012104443|^^|||

OBX|14|TS|^Monitoring Finished^MergeAIMS||20121012110612||||||F|||20121012110612|^^|||

OBX|15|TS|OR.OUT^To Recovery^MergeAIMS||20121012110612||||||F|||20121012110612|^^|||

?

Sample Fluid Output & Balance Message



PV1||O|||||||||||||||||VN01.93|

73



OBX|1|NM|EBLÊstimated Blood Loss^MergeAIMS||20|mL|||||F|||20121012101341|^^|||

OBX|2|NM|NETBALANCE^Net perioperative fluid balance^MergeAIMS||241.12|mL|||||F||||^^|||

?

Sample Anesthesia Types and ASA Class Message



PV1||O|||||||||||||||||VN01.93|


OBX|1|CE|ASAÂSA Class^MergeAIMS||II||||||F||||^^|||

OBX|2|CE|ATYPÂnesthesia Type (Primary)^MergeAIMS|GENERAL|GENERAL^General Endotracheal Anesthesia^MergeAIMS^^^||||||F||||^^|||

OBX|3|CE|AATYPÂdditional Anesthesia Type^MergeAIMS|REGIONAL|REGIONAL^Regional^MergeAIMS^^^||||||F||||^^|||

?

Sample Home/Current Medications Messages (Micromedex)

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012110553||RDEÔ11|20121012110552491|P|2.4|||AL|NE|USA|


PV1||O|||||||||||||||||VN01.93|

ORC||393cbb0d-b112-4d18-a23b-b6e6969f27f2|||IP||||20121011145800|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|||||||||||Clinical HIS^^0000381|

RXE|Q4H^|117382ÔNDANSETRON 2 MG/ML 2 ML VIAL^GFC^00143989105^^NDC|4||MG|||||||||||||10/11/2012 8am|

RXR|ÎV PUSH|

?

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012110553||RDEÔ11|20121012110552531|P|2.4|||AL|NE|USA|


PV1||O|||||||||||||||||VN01.93|

74


ORC||d68b6fb6-fec2-43ba-82b0-f388080a1d1c|||IP||||20121012104700|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|||||||||||DOCUSYS^^58|

RXE|as^needed|112655^Clopidogrel Hydrogen Sulfate^GFC^^^NDC|75||MG||||||||||||||

RXR|Ôral|

?

Sample Delivered Medications Message (Micromedex)

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012110659||ORMÔ01|20121012110658344|P|2.4|||AL|NE|USA|


PV1||O|||||||||||||||||VN01.93|

ORC||356340b8-7f44-42dd-a453-ea9073af89e5|||CM||1||20121012095000|||50012^White^Jonathan^Ron^^ÂMD^|||||||||MergeAIMS^^356340b8-7f44-42dd-a453-ea9073af89e5|

RXE||330541Âmpicillin^CHARGECODE^100195ÂMPICILLIN SODIUM POWDER FOR SOLUTION (Injection (^GFC|1000||mg||||||||||||||||||||10|mL|||||0069-0029-18^Pfizer Laboratories^NDC^00069002918^Pfizer Laboratories^BILLINGNDC|

RXR|IVÎV|

ORC||3121ec95-29f6-46ee-9d4d-ad401f2a796e|||CM||1||20121012095823|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^3121ec95-29f6-46ee-9d4d-ad401f2a796e|

RXE||3330123^FentaNYL 2 mL^CHARGECODE^104349^FENTANYL CITRATE INJECTABLE (Injection (systemic))^GFC|50||mcg||||||||||||||||||||1|mL|||||0409-9093-32^Hospira, Inc.^NDC^00409909332^Hospira, Inc.^BILLINGNDC|

RXR|IVÎV|

ORC||df4daaa1-2a6a-4a2a-9b07-ead51017a203|||CM||1||20121012095900|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^df4daaa1-2a6a-4a2a-9b07-ead51017a203|

RXE||330685^Propofol^CHARGECODE^103285^PROPOFOL EMULSION (Intravenous)^GFC|200||mg||||||||||||||||||||20|mL|||||0703-2856-04^Teva Parenteral Medicines, Inc^NDC^00703285604^Teva Parenteral Medicines, Inc^BILLINGNDC|

RXR|IVÎV|

ORC||d30c8f69-0db5-4304-b7a0-3384870268f3|||CM||1||20121012100000|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^d30c8f69-0db5-4304-b7a0-3384870268f3|

RXE||330558^Rocuronium^CHARGECODE^111553^ROCURONIUM BROMIDE KIT (Injection (systemic))^GFC|40||mg||||||||||||||||||||4|mL|||||^^NDC^^^BILLINGNDC|

RXR|IVÎV|

75


ORC||8f4a16ae-7a57-4094-b3be-396e9a86b32e|||CM||1||20121012100000|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^8f4a16ae-7a57-4094-b3be-396e9a86b32e|

RXE||3300025Âfrin Nasal Spray 0.05%^CHARGECODE^106919ÔXYMETAZOLINE HYDROCHLORIDE SPRAY (Nasal (systemic^GFC|0||||||||||||||||||||||1|Each|||||^^NDC^^^BILLINGNDC|

RXR|NASAL^Nasal|

ORC||c5597814-e2be-4654-9f2a-a4ce56587162|||CM||1||20121012101500|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^c5597814-e2be-4654-9f2a-a4ce56587162|

RXE||3330123^FentaNYL 2 mL^CHARGECODE^104349^FENTANYL CITRATE INJECTABLE (Injection (systemic))^GFC|50||mcg||||||||||||||||||||1|mL|||||0409-9093-32^Hospira, Inc.^NDC^00409909332^Hospira, Inc.^BILLINGNDC|

RXR|IVÎV|

?

Sample Delivered Infusions Message (Micromedex)

MSH|^~\&|MERGEAIMS|Default|CLINICALHIS|FAC1|20121012110659||ORMÔ01|20121012110658261|P|2.4|||AL|NE|USA|


PV1||O|||||||||||||||||VN01.93|

ORC||9fd44c40-4d33-4ee9-bf53-10dabf912bd7|||CM||1^C^M18^20121012100200^20121012102000^||20121012102000|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^9fd44c40-4d33-4ee9-bf53-10dabf912bd7|

RXE|||31.89||mL||Discontinued||||||||||||||||106.29|mL/hr|||||||00264-1482-55^Dopamine in Dextrose 5% Injection, B Braun^NDC^00264148255^Dopamine in Dextrose 5% Injection, B Braun^BILLINGNDC|

RXR|IVÎV|

RXC|B|330914^D5W^CHARGECODE^101084^DEXTROSE SOLUTION (Intravenous)^GFC|250|mL|||00264-1482-55^Dopamine in Dextrose 5% Injection, B Braun^NDC^00264148255^Dopamine in Dextrose 5% Injection, B Braun^BILLINGNDC|

RXC|A|3305681^DOPamine^CHARGECODE^101262^DOPAMINE HYDROCHLORIDE INJECTABLE (Intravenous)^GFC|400|mg|80|mg/mL|^^NDC^^^BILLINGNDC|

ORC||d5de0969-f482-469a-92dc-bb2127f1f14b|||CM||1^C^M33^20121012102000^20121012105300^||20121012105300|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^d5de0969-f482-469a-92dc-bb2127f1f14b|

RXE|||29.23||mL||Discontinued||||||||||||||||53.15|mL/hr|||||||00264-1482-55^Dopamine in Dextrose 5% Injection, B Braun^NDC^00264148255^Dopamine in Dextrose 5% Injection, B Braun^BILLINGNDC|

RXR|IVÎV|

76


RXC|B|330914^D5W^CHARGECODE^101084^DEXTROSE SOLUTION (Intravenous)^GFC|250|mL|||00264-1482-55^Dopamine in Dextrose 5% Injection, B Braun^NDC^00264148255^Dopamine in Dextrose 5% Injection, B Braun^BILLINGNDC|

RXC|A|3305681^DOPamine^CHARGECODE^101262^DOPAMINE HYDROCHLORIDE INJECTABLE (Intravenous)^GFC|400|mg|80|mg/mL|^^NDC^^^BILLINGNDC|

ORC||9e62af2d-941b-4065-8dac-fd7f83406c44|||CM||1^^^^20121012095500^||20121012095500|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^9e62af2d-941b-4065-8dac-fd7f83406c44|

RXE||330011^Lactated Ringers (1,000 mL) IV ^CHARGECODE^102142^LACTATED RINGER’S SOLUTION SOLUTION (Intravenous)^GFC|50||mL||Transferred||||||||||||||||||||||||0338-0117-04^Baxter Healthcare Corporation^NDC^00338011704^Baxter Healthcare Corporation^BILLINGNDC|

RXR|IVÎV|

ORC||87035ed9-c2ec-4038-b2c2-032e39c4becd|||CM||1^^^^20121012100000^||20121012100000|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^87035ed9-c2ec-4038-b2c2-032e39c4becd|


RXR|IVÎV|

ORC||be0bd2c6-f0e1-450a-8b5b-b6e96842c374|||CM||1^^^^20121012102557^||20121012102557|||SG9191^Green^Sam^^Jr^^CRNA^|||||||||MergeAIMS^^be0bd2c6-f0e1-450a-8b5b-b6e96842c374|


RXR|IVÎV|

?

Sample Coding Message (PAE Diagnosis Coding)



PV1||O|||||||||||||||||VN01.93|

DG1|1||401.0^MALIGNANT ESSENTIAL HYPERTENSIONÎ9^^^||20121012073600|W|||||||||0|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|D||20121012073600|

DG1|2||250.02^TYPE II OR UNSPECIFIED TYPE DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, UNCONTROLLEDÎ9^^^||20121012073600|W|||||||||0|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|D||20121012073600|

77


?

Sample Coding Message (Complete Coding from Anesthesia Record)


PID|1||111-11-1111^^^^SSN~MRN01.93^^^FAC1^MR~FA01.93^^^FAC1^CASE~AN01.93^^^FAC1ÂN||LONG_01.93ÂMY^J||19810809000000|F||||||||||AN01.93^^^FAC1ÂN|111-11-1111|

PV1||O|||||||||||||||||VN01.93|

DG1|1||844.1^SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEEÎ9^^^||20121012100156|W|||||||||0|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|D||20121012172009|

DG1|2||401.0^MALIGNANT ESSENTIAL HYPERTENSIONÎ9^^^||20121012095549|W|||||||||0|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|D||20121012172009|

DG1|3||250.02^TYPE II OR UNSPECIFIED TYPE DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, UNCONTROLLEDÎ9^^^||20121012095549|W|||||||||0|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|D||20121012172009|

PR1|1||22556ÂRTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC^C4^^^||20121012100243|P|41.82|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|00626ÂNESTHESIA FOR PROCEDURES ON THE THORACIC SPINE AND CORD, VIA AN ANTERIOR TRANSTHORACIC APPROACH; UTILIZING 1 LUNG VENTILATION^XWALK^^^|68.21|FT9876^Thornton^Frank^^^^MD^|FT9876^Thornton^Frank^^^^MD^|||||

PR1|2||22585ÂRTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)^C4^^^||20121012095600|P|48.53|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|-00003^*** NOT A PRIMARY PROCEDURE CODE ***^XWALK^^^|68.21|FT9876^Thornton^Frank^^^^MD^|FT9876^Thornton^Frank^^^^MD^|||||

PR1|3||22585ÂRTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)^C4^^^||20121012095600|P|48.53|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|-00003^*** NOT A PRIMARY PROCEDURE CODE ***^XWALK^^^|68.21|FT9876^Thornton^Frank^^^^MD^|FT9876^Thornton^Frank^^^^MD^|||||

PR1|4||4048F^DOCUMENTATION THAT ADMINISTRATION OF PROPHYLACTIC PARENTERAL ANTIBIOTIC WAS INITIATED WITHIN 1 HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, 2 HOURS) PRIOR TO SURGICAL INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED) AS ORDERED (PERI 2)^C4^^^||20121012095600|P|48.53|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|^^XWALK^^^|68.21|SG9191^Green^Sam^^Jr^^CRNA^|SG9191^Green^Sam^^Jr^^CRNA^|||||

78


PR1|5||27658^REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON^C4^^^||20121012095600|P|6.25|AMD08031^TestÂnesthesiologist^H.^^ÂMD^|01470ÂNESTHESIA FOR PROCEDURES ON NERVES, MUSCLES, TENDONS, AND FASCIA OF LOWER LEG, ANKLE, AND FOOT; NOT OTHERWISE SPECIFIED^XWALK^^^|68.21|FT9876^Thornton^Frank^^^^MD^|FT9876^Thornton^Frank^^^^MD^|||844.1^SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEEÎ9^^^|51^MULTIPLE PROCEDURES^CPTM^^^|

PR1|6||36620ÂRTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS^C4^^^||20121012171913|I||^^^^^^^|||^^^^^^^|50012^White^Jonathan^Ron^^ÂMD^|||||

PR1|7||99135ÂNESTHESIA COMPLICATED BY UTILIZATION OF CONTROLLED HYPOTENSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY ANESTHESIA PROCEDURE)^C4^^^||20121012095600|P|48.53|AMD08031^TestÂnesthesiologist^H.^^ÂMD^||68.21|FT9876^Thornton^Frank^^^^MD^|FT9876^Thornton^Frank^^^^MD^|||||

?

Sample Surgical Procedures Message


PID|1||111-11-1111^^^^SSN~MRN01.93^^^FAC1^MR~FA01.93^^^FAC1^CASE~AN01.93^^^FAC1ÂN||LONG_01.93ÂMY^J||19810809000000|F||||||||||AN01.93^^^FAC1ÂN|111-11-1111|

PV1||O|||||||||||||||||VN01.93|

PR1|1||27658^REPAIR, FLEXOR TENDON, LEG; PRIMARY, W/O Graft^ScheduledProcedure^27658^REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON^C4||20121012095600|P|6.25||||FT9876^Thornton^Frank^^^^MD^|||2|844.1^SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEEÎ9^^^|51^MULTIPLE PROCEDURES^CPTM^^^|

PR1|2||22812^SPINAL FUSION, 8+ VERT, ANTERIOR^ScheduledProcedure^22556ÂRTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC^C4||20121012100243|P|41.82||||FT9876^Thornton^Frank^^^^MD^|||1|||

?

Sample Allergy Message (AL1, Micromedex)


EVN||20121012105800|


79


PV1||O|||||||||||||||||VN01.93|

AL1|1|Drug|7700060^CEFAZOLIN^MDX^^||N&V||AL

AL1|1|Drug|7700697^HYDROCODONE^MDX^^||Headache||IN

AL1|1|Drug|7702923^PENICILLIN^MDX^^Difficulty breathing, according to mother||Anaphylaxis||AL

AL1|1|Drug|7705145ÊGGS^MDX^^||Anaphylaxis||AL

?

Sample Allergy Message (A60-IAM, Micromedex)


EVN||20121012110107|


PV1||O|||||||||||||||||VN01.93|

IAM|1|DA|7700060^CEFAZOLIN^MDX^^||N&V|U|238^DOCUSYS||AL||||||||C

IAM|1|DA|7700697^HYDROCODONE^MDX^^||Headache|U|242^DOCUSYS||IN||||||||U

IAM|1|DA|7702923^PENICILLIN^MDX^^Difficulty breathing, according to mother||Anaphylaxis|U|^||AL||||||||U

IAM|1|DA|7700223ÂCETAMINOPHEN^MDX^^|||D|241^DOCUSYS||AL||||||||I

IAM|1|DA|7705145ÊGGS^MDX^^||Anaphylaxis|U|239^DOCUSYS||AL||||||||C

?

80

Documents

HL7 Interface Specifications Merge AIMS 8 · PDF fileHL7 Interface Specifications Merge AIMS 8.3 ... Inbound Interface Functionality ... Supported SIU Event Types