1. Acknowledgement Discussion (MSH 15 -16) November 13, 2013 Version 4.0

2. Notes Slides 12-16 added Slide 14-15 set stage (14) and propose solution (15) –See note at bottom of slide 15 for clarifcation Slide 16 is the proposal for both LOI and LRI 2

3. Acknowledgement Background Architecture 1)EHR direct to LIS (no intervening technologies that do anything other than forward messages) 2)EHR connected to Gateway then to LIS 3)EHR connected to Gateway then to second Gateway then to LIS 4)EHR connected to unknown number of intermediate Gateways then to LIS Gateway (or middleware) is technology that: 1)receives messages, 2)optionally validates a message syntax, but usually not the content 3)acknowledges messages (NACK only if validation is done) 4)optionally transforms the message 5)Forwards the message to the next Gateway or LIS 6)Receives the acknowledgement from the next Gateway or LIS 3

4. Desired Behaviors Gateway acknowledges receipt of message (next in chain response) LIS acknowledges message is complete and syntactically correct to EHR (end-to-end) LIS sends error if message is unable to be processed (list of reasons) 4

5. Transactions OML^O21_OML_O21New and append –All levels of acknowledgement OML^O21^OML_O21Cancel (provider) –Control Code in ORC –All levels of acknowledgement ACK^O21^ACKAcknowledge –Next in line ACK – MSH-15/16 NE on response –End to end ACK with MSH-16 NE on response ORL^O22^ORL_O22Application Level Ack –End to end only MSH-16 must be NE on response 5

6. Relevant Segments / Elements MSH – Message Header Segment –MSH-3 Sending Application (Varies, RE) –MSH-5 Receiving Application (Varies, RE) –MSH-10 Message Control ID (ST, R) –MSH-15 Accept Acknowledgement (ID, R) Request type for System Acknowledgement See table HL7 0155 –MSH-16 Application Acknowledgement (ID, R) Request type for Application Acknowledgement See table HL7 0155 MSA – Message Acknowledgement Segment (ID, R) –MSA-1 Acknowledgement Code From table HL7 0008 –MSA-2 Message Control ID (ST, R) ERR – Error Segment –MSH-3 HL7 Error Code From table HL7 0357 –MSH-4 Severity From table HL7 0516 6

7. HL7 Tables (MSH / MSA) 7 HL7 0155 Accept/application acknowledgment ALAlways ERError/reject conditions only NENever SUSuccessful completion only AENEW to accommodate End-to-End HL7 0008Acknowledgment code AAOriginal mode: Application Accept Enhanced mode: Application acknowledgment: Accept AEOriginal mode: Application Error Enhanced mode: Application acknowledgment: Error AROriginal mode: Application Reject Enhanced mode: Application acknowledgment: Reject CAEnhanced mode: Accept acknowledgment: Commit Accept CEEnhanced mode: Accept acknowledgment: Commit Error CREnhanced mode: Accept acknowledgment: Commit Reject

8. Tables (MSA / ERR) 8 HL7 0119 Order Control Codes UAUnable to accept order/service UCUnable to cancel HL7 0357 Message error condition codes 0Message accepted 100Segment sequence error 101Required field missing 102Data type error 103Table value not found 200Unsupported message type 201Unsupported event code 202Unsupported processing id 203Unsupported version id 204Unknown key identifier 205Duplicate key identifier 206Application record locked 207Application internal error HL7 0516Error severity EError FFatal Error IInformation WWarning

9. Transaction Process 9 LIS Gateway 2 Gateway 1 EHR OML AL/ER ACK NE/NE Original Message (Order/Append/Cancel) LIS Gateway 2 Gateway 1 EHR ACK AE/NE End-to-End Acknowledgement ACK NE/NE LIS Gateway 2 Gateway 1 EHR ORL AL/NE Application Level Acknowledgement (on Error) ACK NE/NE 1a/b 2a/b3a/b 4a/b 6a/b5a/b 7a/b 8a/b9a/b 123456789 a MSH-3EHR LIS a MSH-5LIS EHR b MSH-3GT1GT2LISGT2GT1EHRGT2GT1EHR b MSH-5EHR LIS

10. Transaction Process (LIS only AE) 10 LIS Gateway 2 Gateway 1 EHR OML AL/ER ACK NE/NE Original Message (Order/Append/Cancel) LIS Gateway 2 Gateway 1 EHR ACK AE/NE End-to-End Acknowledgement ACK NE/NE LIS Gateway 2 Gateway 1 EHR ORL AL/NE Application Level Acknowledgement (on Error) ACK NE/NE 1a/b 2a/b3a/b 4a/b 6a/b5a/b 7a/b 8a/b9a/b 123456789 a MSH-3EHR LIS a MSH-5LIS EHR b MSH-3GT1GT2LISGT2GT1EHRGT2GT1EHR b MSH-5EHR LIS

11. Transaction Process (no Gateways) 11 LIS EHR OML AE/ER ACK NE/NE Original Message (Order/Append/Cancel) LIS EHR ACK AE/NE End-to-End Acknowledgement ACK NE/NE LIS EHR ORL AL/NE Application Level Acknowledgement (on Error) ACK NE/NE 1a/b 2a/b 3a/b 127 a MSH-3EHRLIS a MSH-5LISEHR b MSH-3LISEHR b MSH-5EHRLIS

12. EHRGateway 1Gateway 2LIS ORDERS ACKNOWLEDGEMENTS David Burgess SenderListener Sender Listener Sender Listener SenderListener Sender Listener Sender Listener Senders always initiate connections, and after delivery switch to listen for a timely response. Once a response is received, or set timeout occurs, it switches back to send mode and will not receive data. Listeners accept data, and when data is received, they reply to the sender to inform them of receipt (generally an accept level acknowledgment.) OML AL/ER ACK NE/NE 1a/b OML AL/ER ACK NE/NE 2a/b OML AL/ER ACK NE/NE 3a/b ORL AL/NE ACK NE/NE 9a/b ORL AL/NE ACK NE/NE 8a/b ORL AL/NE ACK NE/NE 7a/b

13. EHRGateway 1Gateway 2LIS ORDERS ACKNOWLEDGEMENTS Edited (OML is AL/AL) SenderListener Sender Listener Sender Listener SenderListener Sender Listener Sender Listener Senders always initiate connections, and after delivery switch to listen for a timely response. Once a response is received, or set timeout occurs, it switches back to send mode and will not receive data. Listeners accept data, and when data is received, they reply to the sender to inform them of receipt (generally an accept level acknowledgment.) OML AL/AL ACK NE/NE 1a/b OML AL/AL ACK NE/NE 2a/b OML AL/AL ACK NE/NE 3a/b ORL AL/NE ACK NE/NE 9a/b ORL AL/NE ACK NE/NE 8a/b ORL AL/NE ACK NE/NE 7a/b

14. EHR Gateway 1 Gateway 2 LIS Orders and Reporting Environment Sender Listener Sender Listener Sender Listener SenderListener Sender Listener Sender Listener Senders always initiate connections, and after delivery switch to listen for a timely response. Once a response is received, or set timeout occurs, it switches back to send mode and will not receive data. Listeners accept data, and when data is received, they reply to the sender to inform them of receipt (generally an accept level acknowledgment.) O1a/b ACK NE/NE O2a/b OML AL/NE ACK NE/NE O3a/b ORU AL/NE ACK NE/NE R3a/b ORU AL/NE ACK NE/NE R2a/b ORU AL/NE ACK NE/NE R1a/b Orders Results OML AL/NE MSG aa/bb MSG: OML/ORU/OML aa = MSH-15 bb = MSH-16 Xna/b X:O=Orders,R=Results n pt-pt txn number, a=forward txn (e.g. OML/ORU/OML) b=response (e.g. ACK) ACK NE/NE ACK NE/NE is synchronous response

15. EHR Gateway 1 Gateway 2 LIS Guaranteed Delivery and Validation Sender Listener Sender Listener Sender Listener SenderListener Sender Listener Sender Listener Senders always initiate connections, and after delivery switch to listen for a timely response. Once a response is received, or set timeout occurs, it switches back to send mode and will not receive data. Listeners accept data, and when data is received, they reply to the sender to inform them of receipt (generally an accept level acknowledgment.) O1a/b R4a/b ACK NE/NE O2a/b R5a/b OML AL/AL ACK NE/NE O3a/b R6a/b ORU AL/AL ACK NE/NE R3a/b O5a/b ORU AL/AL ACK NE/NE R2a/b O5a/b ORU AL/AL ACK NE/NE R1a/b O4a/b Orders Results OML AL/AL MSG aa/bb MSG: OML/ORU/OML aa = MSH-15 bb = MSH-16 Xna/b X:O=Orders,R=Results n pt-pt txn number, a=forward txn (e.g. OML/ORU/OML) b=response (e.g. ACK) ACK NE/NE ACK AL/NE ACK OML Notes: 1) All LISs and Certified EHRs support both electronic orders and results communication – general statement – does not apply to every client 2) Propose to have application acknowledgement (success or error) use the other path (e.g. result acknowledgement via order path) to respond asynchronously -- receiver splits message based on message type ORU ORL ACK NE/NE is synchronous response ORL AL/NE

16. Proposal for LOI MSH – 15 – OML AL – required - default NE – optional - if pt-pt environment where transport protocols guarantee delivery to intended recipient SU and ER are not valid – ORL AL – required NE - optional SU, ER – are not valid – System ACK NE only AL, SU, ER – are not valid MSH – 16 – OML AL – required - default ER – optional - if pt-pt environment where transport protocols guarantee delivery to intended recipient SU and NE are not valid – ORL NE - required AL, SU, ER – are not valid – System ACK NE – required AL, SU, ER – are not valid

17. Proposal for LOI Motion to accept as proposed slide 16 (15 as clarification) for Orders. Bob Dieterle, David Burgess –Clarify the Xna/b in subsequent version as it is confusing. –Suggest to use AL/AL. Is the default. –Problem to distinguish between application level vs. system acknowledgement when using ACK on ORU. Suggest to use MSH-21 profile component Split LOI and LRI –Against: 4, Abstain: 5, In Favor: 12 Motion to re-open item #20. Bob Dieterle, Riki Merrick See spreadsheet for vote 17

18. Proposal for LRI MSH – 15 – ORU AL – required - default NE – optional - if pt-pt environment where transport protocols guarantee delivery to intended recipient SU and ER are not valid – Application ACK AL – required NE - optional SU, ER – are not valid – System ACK NE only AL, SU, ER – are not valid MSH – 16 – ORU AL – required - default ER – optional - if pt-pt environment where transport protocols guarantee delivery to intended recipient SU and NE are not valid – Application ACK NE - required AL, SU, ER – are not valid – System ACK NE – required AL, SU, ER – are not valid