Responsibilities of Receivers of medical documents regarding coding and storing documents

Decision Status: Completed

Background

In a fully interoperable health system, medical documents could be received by a medical institution at any time and with any amount or quality of document metadata. Presumably, the document is being sent to serve an existing or future patient at the receiving institution. Ideally, the sender would set up an information exchange agreement with the receiver, and they would trial document types and exchange mappings. In emergent situations, that may not be possible, and accommodations need to be made. In such a circumstance, it's important for the receiving institution to incorporate the received documents into its regular document display system so that clinical teams can find the document types in the usual manner. The receiving institution's ability to achieve this depends on the quality of the metadata in the received documents. The ethical obligation is to do a reasonable amount for patient care, and the legal obligation is uncertain at this time. 

Options

Options:

1.     All custom-built repositories be able to accept any Canadian LOINC code automatically

2.     All EHSs be able to accept any Canadian LOINC code and map to any internal classification system automatically

3.     All EHSs or repositories urgently map to an equivalent (generalized type is acceptable) LOINC code or internal code by hand (advice given by Editorial Guidelines) if it can match an internal document type. 

4.     If document type doesn’t exist in EHS or repository then code to an ”Miscellaneous document” type (needs a Canadian  extension code)

Discussion

"All EHSs be able to accept any Canadian LOINC code and map to any internal classification system automatically" is too hard to achieve

There is typically a process to ask permission to send a document so that the receiver checks if they should accept it. There are a few documents that can’t be accepted (autopsy reports).

Add, “Assumption: the receiver has a process of accepting documents and does so routinely.”

Note: EHS includes EMR.

EMRs have more flexibility in accepting documents, but they are not as good at putting them in the right place.

What is the legal responsibility to accept elements of the patient record? Can you reject? Can you accept but in a way that is not as easy to find? IF you do accept and place properly, how fast do you need to do it?

Miscellaneous filing is being used today.

Do we need to separate the re-coding and placing in the hierarchy? EMRs and EHS’s and Repositories have different obligations here.

Basically it boils down to: If the file meets Canadian standards, EMRs, EHRs, and Repositories should accept it and make available quickly to their clinicians. This is the advantage of having a canadian ontology. Yes, this might require work to map it so if you can’t, at least put it in a miscellaneous category and warn users.

From a senior Health Informatics Professional:

1.If document type doesn’t exist in EHS then code to an ”Miscellaneous document” type (needs a Canadian extension code) that is policy‑defined and allows the document to be clinically visible, searchable, and tracked for governance

2.It is recommended that the EHSs map to an equivalent (generalized type is acceptable) LOINC code or internal code by hand (advice given by Editorial Guidelines) if the documentcan match an internal document type. 

Decision

SENT DOCUMENT	EHR	Repository	EMR
Has Canadian LOINC that is used in receiving system	Accept in normal patient chart structure	Accept in EHR - Certain document types can be excluded from viewing on a policy basis	Accept in EMR
Has Canadian LOINC that is NOT used in receiving system	Accept in Miscellaneous document structure (visible, trackable) Or  Matched to more generalized LOINC code	All Canadian LOINC codes are accepted in Repositories. Certain document types can be excluded from viewing on a policy basis	Accept in Miscellaneous document structure (visible, trackable) User is warned
Does NOT have Canadian LOINC code or is missing a code	Accept in Miscellaneous document structure (visible, trackable) Inform Sender	Accept in Miscellaneous document structure (visible, trackable) Inform sender	Accept in Miscellaneous document structure (visible, trackable). The user is warned EMR vendor is notified

  

The discussion and voting on this issue was done in stages:

all votes were:

MB:5

NS: 5

MK: 5

DL:  5

IB: 5

Re:  There is a matching LOINC Code

Guideline

The expectations of health system who are receiving a document expediently (without time for a normal information exchange agreement to be set up, exchange of document code mapping and testing to be done)

SENT DOCUMENT	EHR	Repository	EMR
Has Canadian LOINC that is used in receiving system	Accept in normal patient chart structure	Accept in EHR - Certain document types can be excluded from viewing on a policy basis	Accept in EMR
Has Canadian LOINC that is NOT used in receiving system	Accept in Miscellaneous document structure (visible, trackable) Or  Matched to more generalized LOINC code	All Canadian LOINC codes are accepted in Repositories. Certain document types can be excluded from viewing on a policy basis	Accept in Miscellaneous document structure (visible, trackable) User is warned
Does NOT have Canadian LOINC code or is missing a code	Accept in Miscellaneous document structure (visible, trackable) Inform Sender	Accept in Miscellaneous document structure (visible, trackable) Inform sender	Accept in Miscellaneous document structure (visible, trackable). The user is warned EMR vendor is notified