1. The First Polish Nationwide Implementation Guide for HL7 CDA
Roman Radomski, iEHR.eu
22 Nov 2013, London

2. eHealth in Poland
The main project of Polish eHealth aims at building the central information system supporting common exchange of electronic medical documents.
Three types of documents: eReferral, ePrescription and eOrder of Supply are to be uploaded to the central repository to be accessed by the potential service providers.
Other documents are to be stored locally, but their metadata will be sent to the same central system and published in the form of document registry.

3. HL7 v3 Implementation Guide
HL7 CDA and V3 have been chosen as the standards for documents and messages to be exchanged with the central system.
Due to the official project timeline, the large scale amendments of the current regulations and printed document forms were excluded.
Draft CDA implementation guide for all 3 document types has been developed by iEHR.eu and distributed by the official government agency CSIOZ for review.
The message template for other documents metadata exchange has been designed on the basis of the HL7 Medical Records R-MIM.

4. The overall model of IG artifacts

5. Templates defined in IG

6. Local extensions
Most of the clinical concepts represented in the documents have been successfully mapped to the CDA, although 8 local extensions had to be defined.
One extension has been defined for the HL7 v3 message being sent to the central repository.

7. Entitlement document
The clinical document may contain information on non-clinical document allowing patient’s entitlement to the particular medical service coverage plan.
The information consists of the document type and the document number (identifier).
The special entitlement resulting from the document is not explicit in the document.
The entitlement is subject to the operational context (planned service, local conditions, region) and may vary in time, but it does not change the document information.

8. Entitlement document
id.root = OID nodes for entitlement documents identifiers
code.codeSystem = OID node for entitlement documents types value set
Constraint: Document id and code

9. Special entitlement
There are special entitlements (e.g to the drug refund coverage plans) that should be indicated in the prescription document.
The dictionary of those coverage plans is regulated by law.

10. Special entitlement code.code = "PUBLICPOL"
code.codeSystem = " ” (ActInsurancePolicyCode)
code.qualifier.name.code = "RLEKUD" (drug refund based on special entitlement)
code.qualifier.name.codeSystem = OID node for coverage plans value set
code.qualifier.value.codeSystem = OID node for special entitlements value set
Constraint: CoveragePlan.code

11. Coverage eligibility confirmation
There is a procedure for online confirmation of patient eligibility to the national health insurance.
The confirmation has a form of a string and needs to be included in the clinical document issued when refunded service is performed.
The confimation string is not an identifier of an insurance policy or any other entitlement document.

12. Coverage eligibility confirmation
id.root= OID node for coverage eligibility confirmation identifiers
code.code = "ELG " (eligible)
code.codeSystem = " " (ActCoverageEligibilityConfirmationCode)
Constraint: CoverageEligibilityConfirmation id and code

13. Multiple birth indicator and order number
Newborns are identified by their mother identifier and the birth date.
Multiple birth newborns are identified by their mother identifier, the birth date and the birth order number.
All those identifying data needs to be included in every clinical document until the proper national identifier is given - usually it takes couple of weeks.

14. Multiple birth indicator and order number

15. Close person
There are specific document forms in Poland which require providing given names of patient’s parents as an additional patient identifying information.
This is not an information about patient’s guardian.
This is not a participation in the act of clinical document or in any act being documented.
The document does not contain any other information about patient’s parents.

16. Close person
code.codeSystem = " " (PersonalRelationshipRoleType)
Constraint: PersonalRelationship.code

17. Physician speciality
Prescriptions for specific drugs and medical equipment supply require to be issued by physicians of particular specialities.
Common practice is to include all medical specialities of document authenticator in every clinical document issued.
The document content and context may not be relevant to the physician’s medical speciality.
The dictionary of medical specialities is regulated by law.

18. Physician speciality
code.codeSystem = OID node for physician specialities value set
Constraint: Qualification.code

19. Drug payment level
Drug may be refunded on various levels according to the public insurance/coverage plan.
The same drug may be refunded on different levels depending on clinical context.
Physician is expected to determine the patient’s payment level for the drug being prescribed.
The dictionary of drug payment levels is regulated by law.
The national health fund conducts continous fraud detection to ensure proper drug refund processes.

20. Drug payment level code.code = "PUBLICPOL"
code.codeSystem = " ” (ActInsurancePolicyCode)
code.qualifier.name.code = "POLEKR" (refunded drugs payment levels)
code.qualifier.name.codeSystem = OID node for coverage plans value set
code.qualifier.value.codeSystem = OID node for refunded drugs payment levels value set
Constraint: CoveragePlan.code

21. Drug substitution
The default rule is that pharmacist can substitute the prescribed drug with its equivalent, unless the drug prescription contains „no substitution” remark.
The problem of drug substitution is rather sensitive, due to business competition between pharmaceutical companies and its potential influence on the medical professionals.

22. Drug substitution code.code = "N" (none)
code.codeSystem = " " (ActSubstanceAdminSubstitutionCode)
Constraint: Substitution.code

23. Supporting Clinical Statement
The message containing metadata of clinical document being issued is sent to the central repository.
This message has to contain information about diagnosis placed in the context of the document.

24. Supporting Clinical Statement
Medical Records
Clinical Statement
code.codeSystem = OID node for official Polish translation of ICD-10
Constraint: Observation.code

25. New Timeline for the Polish eHealth Agenda
The central system (P1) to be ready by mid 2014
First production use of P1 at beginning of 2015
The electronic drug prescription obligatory for all healthcare providers in 2015 or 2016
Other documents will be obligatory gradually from 2016