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NHS Wales Diagnostics Use Cases

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#1 View a list of test results/reports for a patient

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#2 View a test result

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#3 View graph of previous results for a selected test item

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#4 Request a diagnostic test for the patient

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Welsh Results Reporting Service Architecture

  • There are three main of contributing systems:
    • National LIMS
    • Welsh Radiology Information Service
    • ‘Other’ systems such as local Cardiology, Endoscopy systems etc.

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  • Clinicians view diagnostic test results/reports and send test requests tests using a clinical portal

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  • The clinical portal gets test results from and sends test requests to Welsh Results Reporting Service

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Welsh Results Reporting Service Architecture

FHIR could be adopted in place of

  • The legacy API used to retrieve patient diagnostic data
  • HL7v2 messages*

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* This would provide value – but is not a priority for Wales

This diagram zooms in a bit to show more detail.

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  • Contributing systems send data using HL7v2 messages
  • These messages are queued, and data sent to the database via a processor.
  • The clinical portal retrieves test results and sends requests via a legacy SOAP interface

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We developed a FHIR facade here

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What are the existing standards for FHIR Diagnostic Reports?

  • UK Core draft profiles for DiagnosticReport
  • Australia Core
    • AU Base Pathology Report
    • AU Base Diagnostic Imaging Report
    • AU Base Diagnostic Report
  • US Core
    • US Core DiagnosticReport Profile for Report and Note Exchange
    • US Core DiagnosticReport Profile for Laboratory Results Reporting

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It made the most sense to us to have a profile for structured lab results, and a profile for other reports - following US Core

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  • Why might a separate profile for Laboratory Results Reporting be required?

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  • If so, do we need any further ‘specialist’ profiles for other Diagnostic Reports?

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Imaging Investigation Result Structure

Imaging investigation results were easily mapped to the UK Core DiagnosticReport profile.

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Cardiology Result (as embedded PDF)

Cardiology and other results containing an embedded PDF were easily mapped to the UK Core DiagnosticReport profile.

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But - laboratory results are more complex…

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  • Consider a report containing multiple panels e.g.
    • Urea and electrolytes
    • Estimated GFR

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Laboratory Test Result Structure

MSH|^~\&|154|7A1A4^Wrexham Maelor|200|200|201805111147||OUL^R22^OUL_R22|854086|P|2.5|||||GBR||EN

PID|||6163458028^^^NHS^NH~201674^^^154^PI~A710343^^^140^PI||BURGER^GEORGE||19781209|M|||818 NEWPORT RD^RUMNEY^CARDIFF^^CF3 8LH|||||||||||||||||||N

NTE|1||Abscess drainage NOS|H^Clinical History^TCL

PV1||N|7A4BWRIEW^^^^^^^^CRI Elizabeth Ward||||C3292949^MCLAIN^ALISON JANE^^^Dr|||710|7A1A4^^^^^^^^Wrexham Maelor|||||||NH|5000117529^^^154|||||||||||||||||||||||||20180511113400

SPM|1|^5000117529||06^SER-GEL^TCL|||||||||||||20180511113400|20180511114400

OBR|1||5000117529-1-B3087^154|44JB.^Urea and electrolytes^RC^B3087^UE^TCL||20180511114500||||||||||C3292949^MCLAIN^ALISON JANE^^^Dr|||||1|20180511114600||B|F

ORC|SC||5000117529-1-B3087^154||||||20180511114638|||C3292949^MCLAIN^ALISON JANE^^^Dr|||||||||Cardiff and Vale University Local Health Board

OBX|1|SN|44I5.^Sodium^RC^B3582^NA^TCL|1|^140|mmol/L^^TCL|133-146|N|||F|||20180511114600||ce125415

OBX|2|SN|44I4.^Potassium^RC^B3571^K^TCL|2|^4.0|mmol/L^^TCL|3.5-5.3|N|||F|||20180511114600||ce125415

OBX|3|SN|44J9.^Urea^RC^B3594^Urea^TCL|3|^3.0|mmol/L^^TCL|2.5-7.8|N|||F|||20180511114600||ce125415

OBX|4|SN|44J3.^Creatinine^RC^B3541^CREAT^TCL|4|^100|umol/L^^TCL|58-110|N|||F|||20180511114600||ce125415

OBR|2||5000117529-1-B3047^154|451E.^Estimated GFR^RC^B3047^EGFR^TCL||20180511114500||||||||||C3292949^MCLAIN^ALISON JANE^^^Dr|||||2|20180511114600||B|F

ORC|SC||5000117529-1-B3047^154||||||20180511114648|||C3292949^MCLAIN^ALISON JANE^^^Dr|||||||||Cardiff and Vale University Local Health Board

NTE|1|L|This is an estimate of GFR and is not valid in situations of rapidly changing serum creatinine. See www.renal.org for further information on this and other limitations of its use.

OBX|1|SN|44J3.^Creatinine^RC^B3541^CREAT^TCL|1|^100|umol/L^^TCL|58-110|N|||F|||20180511114600||ce125415

OBX|2|SN|451E.^Estimated GFR ^RC^B3550^EGFR^TCL|2|^72|ml/min/1.73m2^^TCL||N|||F|||20180511114600||ce125415

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What should the profile and Implementation Guidance for laboratory results define?

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  • A fixed code of ‘LAB’ should be included as a category code

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  • Because lab reports can be modelled in several different ways, the DiagnosticReport profile and IG guidance should specify a structure – i.e.
    • Test results are carried in Observation Groups e.g. U&R, eGFR, Full Blood count etc.
    • Observation groups contain nested result item Observations (and not components)

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  • Result item Observations can be used to graph a series of test result items

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  • Observations should contain a code (preferably a SNOMED code from the Unified Test List) to tell you what is being measured*

* Legacy data may not contain SNOMED codes from the Unified Test List – need to provide guidance here too

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Links

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  • AU Base Implementation Guide

http://build.fhir.org/ig/hl7au/au-fhir-base/index.html

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  • US Core

http://build.fhir.org/ig/HL7/US-Core/

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  • Data Standards Wales FHIR IG (v0.0.3 Discovery)

https://simplifier.net/guide/FHIR-Standards-Wales-Implementation-Guide/Home/Guidance/Diagnostic-Reports?version=current