Stream: argonaut
Topic: Question about US Core Clinical Notes
Yunwei Wang (Jan 09 2020 at 22:49):
I understand that a clinical notes must have five DocumentReference. I am confused about the requirement for the three DiagnosticReports (Cardiology, Pathology, and Radiology) mentioned in US Core Clinical Notes Guidelines. There are four places related to these three reports:
1) In https://build.fhir.org/ig/HL7/US-Core-R4/clinical-notes-guidance.html#clinical-notes, it says that "three DiagnosticReport categories which systems should support"
2) In the same section, next paragraph says "They represent the minimum set a system must support to claim conformance to this guide"
3) In https://build.fhir.org/ig/HL7/US-Core-R4/clinical-notes-guidance.html#support-requirements, it says that "This guide requires systems ... to support a minimum of the three report categories"
4) In https://build.fhir.org/ig/HL7/US-Core-R4/StructureDefinition-us-core-diagnosticreport-note.html#mandatory-and-must-support-data-elements, it says that "The DiagnosticReport.category binding must support at a minimum the US Core DiagnosticReport Category Codes of Cardiology, Radiology, and Pathology. Other categories may be supported."
My understanding is the first one (with wording should) contradicts with the other three (with the wording minimum).
Which one is correct? Is a US Core clinical notes required/mandatory to have these three reports or not?
@Brett Marquard
Thanks
Brett Marquard (Jan 10 2020 at 15:43):
Thank you Yunwei for pointing out the inconsistency. The guidance on the profile page is the final word. Systems must support those three categories.
Yunwei Wang (Jan 10 2020 at 16:54):
Do you need to JIRA ticket to fix that?
Brett Marquard (Jan 10 2020 at 20:20):
please
Yunwei Wang (Jan 17 2020 at 17:32):
Another question. Section 2.2.1.2 "In order to enable consistent access to scanned narrative-only clinical reports the Argonaut Clinical Note Server SHALL expose these reports through both DiagnosticReport and DocumentReference by representing the same attachment url using the corresponding elements listed below."
- Does the SHALL apply to "scanned narrative-only clinical reports" ONLY?
- If yes, how do I know if the attachment is a "scanned narrative-only clinical reports". Assume it is a PDF, there are still generated PDF vs scanned PDF.
Yunwei Wang (Jan 17 2020 at 17:34):
@Brett Marquard @Eric Haas
Brett Marquard (Jan 21 2020 at 13:46):
ALL notes are accessible through DocumentReference. Ideally, Imaging/Cardiology/Lab/etc. are available through DiagnosticReport. The issues is not all systems categorize their scanned reports as 'Imaging' -- they just get marked as scanned note
Yunwei Wang (Jan 21 2020 at 15:22):
So I cannot say the an attachment must be cross referenced by both DocumentReference and DiagnosticReport. Is that correct?
Brett Marquard (Jan 21 2020 at 18:26):
All DiagnosticReports can be Cross referenced by Document Reference.
Brett Marquard (Jan 21 2020 at 18:27):
Not all DocumentReference can be cross referenced by DiagnosticReport since some DocumentReferences point to notes that are not DiagnosticReports!
Yunwei Wang (Jan 21 2020 at 18:28):
You mean all "attachments" in DiagnosticReport. Right?
then, should that statement in 2.2.1.2 be clarified in IG?
Brett Marquard (Jan 21 2020 at 18:30):
Please let me know how you want us to improve this text :"For example, when DiagnosticReport.presentedForm.url references a Scan (PDF), that Attachment SHALL also be accessible through DocumentReference.content.attachment.url.(See Figure 2) This guide requires servers implement the duplicate reference to allow a client to find a Pathology report, or other Diagnostic Reports, in either Resource. If servers properly categorized scanned reports and used the correct resource per report type (e.g. Pathology scan in DiagnosticReport) this wouldn’t be required."
John Moehrke (Jan 21 2020 at 18:30):
No, a DocumentReference.content.attachment.url can point at a DiagnosticReport. given that the element in DocumentReference is simply a URL, it can point at FHIR resources or anything else. Hence DocumentReference can index anything. -- Note that "Document" in the context of DocumentReference is the broader definition of "Document" as defined in http standard, not limited to CDA like documents.
John Moehrke (Jan 21 2020 at 18:33):
so, is it only attachmets? that are common, or is the relationship a hierarchy (DocumentRefernece -> Binary or DiagnosticReport; where DiagnosticReport may point at another Binary?)
John Moehrke (Jan 21 2020 at 18:33):
simple diagram may be better than words
Brett Marquard (Jan 21 2020 at 18:33):
agree - seee pasted image
Brett Marquard (Jan 21 2020 at 18:34):
Brett Marquard (Jan 21 2020 at 18:34):
Yunwei Wang (Jan 21 2020 at 18:44):
My confusion is on the paragraph above this, esp the "scanned narrative-only clinical notes". For example, is an x-ray report with images "narrative-only"?
Ruth berge (Apr 29 2021 at 22:49):
On the US Core Diagnostic Report and Note page (http://hl7.org/fhir/us/core/STU3.1.1/StructureDefinition-us-core-diagnosticreport-note.html) is a link and description of the Diagnostic Report Category (extensible). A similar concept with different categories is also on the Laboratory variant of DiagnosticReport. If I select to look at the list of category codes , a new page opens http://hl7.org/fhir/us/core/STU3.1.1/ValueSet-us-core-diagnosticreport-category.html. On this page are three codes identified as LOINC Code Display
LP29684-5 Radiology
LP29708-2 Cardiology
LP7839-6 Pathology
If I click on the link for each code, I get a loinc error page indicating that the link is bad. If I search in LOINC for these codes, I also am unable to find them. So at the very least, the US Core FHir page should be corrected to have working links. I am looking at the latest version. At a different level, it is not clear at all whether the category should be just that- a category that could include many different types of Radiology, Cardiology, and Pathology reports or if it has some other meaning. In main FHIR this maps to a Diagnostic Service Section which is an easily relatable concept. I am guessing that the US Core didn't want the local codes that are allowed in the Diagnostic Service Section list so instead they imposed a rule that everything has to be categorized in one of these three codes. So- two questions: Can the links be fixed so that the codes can be seen in LOINC ? Can there be a better description in US Core to make it clear that multiple Diagnostic Service Sections codes can and should be mapping to the three examples presented - for example the HL7 table 0074 Diagnostic Service section code for CT could map to this LP29682-5 Radiology code? note that the US core document cites Loinc 2.68 but Loinc is now at 2.69.
Eric Haas (Apr 29 2021 at 23:29):
Can the links be fixed so that the codes can be seen in LOINC ?
the bad loinc links was a known issue and fixed for the next version
Eric Haas (Apr 29 2021 at 23:33):
US core document cites Loinc 2.68 but Loinc is now at 2.69.
Can you clarify where you saw the version of LOINC referenced ? I did a search and did not find it. We rely on the ig-publisher terminology server to update the code systems to the latest versions. perhaps this is on their todo list.
Eric Haas (Apr 29 2021 at 23:42):
Can there be a better description in US Core to make it clear that multiple Diagnostic Service Sections codes can and should be mapping to the three examples presented - for example the HL7 table 0074 Diagnostic Service section code for CT could map to this LP29682-5 Radiology code?
US Core documents the minimum requirements, so implementers can use as many categories schemes as they want because the cardinality of the element is 0..* and the binding is extensible.
Whether categories codes should be mapped to the example binding of Diagnostic Service Section Codes is an opinion and has not been raised the implementers before.
Ruth berge (Apr 30 2021 at 16:32):
@Eric Haas Screen-Shot-2021-04-30-at-9.16.42-AM.png
Eric Haas (Apr 30 2021 at 17:29):
yes the screenshot show the valueset expansion which is based on the common ig-publisher's terminology server. I don't know the update policy for LOINC but maybe @Rob Hausam does.
Ruth berge (Apr 30 2021 at 18:00):
A follow up question is... given that these are examples , how would I find other codes that can meet the criteria set out by US Core as to what comprises a default scheme? LP means these are Loinc Parts I think but not finding them in the base lookups in LOINC. Perhaps I have to download and use RELMA? Would it be possible for US Core the explain this rather than just throwing a non-working example? That would help implementers to understand and find alternatives.
Eric Haas (Apr 30 2021 at 21:23):
What do you mean by a non working example?
Ruth berge (May 01 2021 at 04:48):
Hi, what I mean is that the examples provided don't link. An explanation of the logic behind choosing the LP types would at least provide the background information about what we should look for in LOINC to find similar codes that could properly extend the category, per the authors of US Core. What is the criteria that distinguishes the Loinc codes used for the category? Aside from that is the separate issue that FHIR probably would not address that searching for these in Loinc is different. I did find a way to retrieve the descriptions from the API but still not understanding how I could find an appropriate category to match many of the codes in OBR-24. I'm just looking for a deeper explanation of what the authors of US Core are expecting to find in the category. Thanks.
Brett Marquard (May 03 2021 at 14:09):
During US Core/Argonaut Clinical Note design we learned clinical systems have developed custom note types. Exactly what site specific concepts will mapped to these LP will unfortunately vary by deployment. I do believe over time LOINC will be able to provide exactly which LOINC codes match up with each LP, and then clinical systems will be able to use these to guide their mappings.
Eric Haas (May 03 2021 at 16:04):
Hi, what I mean is that the examples provided don't link.
examples provided don't link to what exactly? - can you clarify and provide a screen shot or a specific reference to what is not linking in the examples so we can fix it if it is a broken link?
Last updated: Apr 12 2022 at 19:14 UTC
