EDIFACT Message Implementation Guide for Diabetes Report
Based upon MEDDBS Proposal February 1997
Version 1.0 7. February 2000 Status: For nation-wide implementation
KITH Report 5/00 ISBN 82-7846-082-5
KITH-report
Title
Edifact Message Implementation Guide for Diabetes Report
Status: For nation-wide implementation
Author(s)
Kompetansesenter for IT i helsevesenet AS
Postal address
Sukkerhuset N-7489 Trondheim
Visiting address
Sverresgt 15, inng G
Phone
+47-73 59 86 00
Fax
Edgar Glück
Client(s)
+47-73 59 86 11
e-mail
The Ministry of Health and Social Affairs / Program for Standardisation and Coordination
firmapost@kith.no
Enterprise No.
959 925 496
Report number URL Project No.
R 5/00
ISBN
http://www.kith.no/rapportarkiv/diabetes-ig-meddbs -10.pdf
Date No. of pages Quality assurance Classification
82-7846-082-5
Approved by:
7. Feb. 2000
60
Annebeth Askevold
Open
Kenneth R. Iversen Man. Dir. (Act.)
Abstract
The implementation guide for the diabetes report is performed as a part of the program ”Standardisation and Coordination of Information Interchange in Healthcare" (in Norwegian: “Standardisering og samordning av informasjonsutveksling i helsevesenet"). Norwegian Centre for Medical Informatics (KITH) is responsible for the implementation of this program on behalf of The Ministry of Health and Social Affairs. This implementation guide specifies the Norwegian subset of the information content of the EDIFACT-message proposal MEDDBS from February 1997, and how this message is to be used for electronic interchange of diabetes reports. This message is designed to meet the requirements of the World Health Organisation (WHO) St. Vincent declaration. The message is tested in a pilot project.
Edifact Message Implementation Guide for Diabetes Report Preface
Preface
The MEDDBS message specified in this Message Implementation Guide (MIG) is an implementation of a message proposal from the EMEDI PanEuropean user group for Medical EDI developed by WHO’s Diabcare project. The Norwegian MIG uses a subset of the international message. This subset has been defined by a national group. Compared to earlier national MIGs this document only contains a detailed description of the parts included in the Norwegian subset. The readability of the document has been in focus by removing details which are of little relevance and by adding better explanations for main concepts in order to reduce the chances for misunderstandings and incorrect implementations. This document has been produced by the tool EdiView which should further secure the consistency of the information content. It cannot be avoided that a document of this size and complexity contains errors and imperfections. Corrections of errors and suggestions for improvement - in content or presentation - will be received with gratitude.
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Edifact Message Implementation Guide for Diabetes Report Table of contents
Table of contents
1 Introduction 2 References 3 Notation 1 3 5
3.1 Mapping of objects and their attributes ................................................................................5 3.2 Occurrences of data elements, segments and segment groups .......................................5 3.3 Representation of information ...............................................................................................6 3.4 Length of data elements.........................................................................................................6 3.5 Coding scheme identification................................................................................................6 3.6 Codes.......................................................................................................................................7 3.7 Other issues.............................................................................................................................7
4 Scope of the message
9
4.1 Function....................................................................................................................................9 4.2 Limitations ...............................................................................................................................9
5 Message structure and content
11
5.1 Message content...................................................................................................................11 5.2 Message structure ................................................................................................................11 5.3 Message subset....................................................................................................................17
6 Detailed message content
23
6.1 Message header...................................................................................................................23 6.2 Message body.......................................................................................................................27
Patient administrative information.................................................................................................................................. 27 Clinical information item.................................................................................................................................................... 30 Clinical investigation........................................................................................................................................................... 34 Treatment .............................................................................................................................................................................. 38
6.3 Message trailer .....................................................................................................................41
Annex A Annex B Annex C Annex D
Segment Mapping MEDDBS Message Examples Mapping of Objects Report Schema
43 45 49 53
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Edifact Message Implementation Guide for Diabetes Report Introduction
1 Introduction
This document describes how Diabetes reports are to be exchanged electronically in Norway. This Message Implementation Guide describes a subset to be used in Norway and is based upon the work done inside WHO's Diabcare project as implemented by EMEDI. This message is designed to meet the requirements of the World Health Organisation (WHO) St Vincent declaration. This declaration defined a worldwide form to report clinical information on patients with diabetes, and the paper form is referred to as “the Basic information sheet”. This EDIFACT message supports exactly the information required in this form. This MIG specifies a number of code values currently not defined in the EDIFACT code directory (mostly specified as Znn).
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Edifact Message Implementation Guide for Diabetes Report References
2 References
This document is based upon and refers to the following documents:
1) 2) 3) 4) 5) UN/EDIFACT MEDDBS Diabetes report message proposal from 02.97 Norsk veiledning i bruk av EDIFACT (Norwegian EDI Guide) UN/EDIFACT directory, version D.96B and some code values from newer directories. KITH R4/94 Meldingshåndbok for Elektronisk informasjonsutveksling i helse- og trygdesektoren, versjon 2.1, Mars 1994 (Message Guide for Electronic Information interchange in Healthcare). UN/EDIFACT Guidelines for MIG
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Edifact Message Implementation Guide for Diabetes Report Notation
3 Notation
The documentation is in accordance with the current UN/ECE Guide for Guidelines recommendations.
3.1 Mapping of objects and their attributes
Every segment group, representing one object or part of an object in the information model, is started on a new page with a broad, grey shaded box including information about this segment group, its usage, definition and any comments. In some instances several objects in a GMD have been combined into one segment group in the message. The box indicating the segment group is continued as a grey shaded at the left side of the successive pages. Inside the shaded box to the left are the names of the attributes of the actual object. To the right of the attribute name is the segment that the attribute is mapped into indicating the exact data element in the segment that is conveying this information. If the attribute may be represented both as a code value and as a code meaning, which is both parts of a composite data element, than the attribute is mapped to the coded element only. Every segment group is started with a mandatory segment, which can only occur once - the trigger segment of the segment group.
3.2 Occurrences of data elements, segments and segment groups
In the message definition segments and segment groups that have to be present are indicated by M (Mandatory) while segments and segment groups that are not required to be present are indicated by C (Conditional). If a segment, data element or segment group may occur several times, this is specified with a number (1, 9 or 99, etc.) following its usage indicator. M 9 specifies that this data element, segment or segment group have to occur at least once and at most 9 times. The actual usage of every segment, composite and data element is indicated in the detailed segment description by its usage indicator according to the UN/EDIFACT proposal for MIGs:
• • • • • •
M (Mandatory) R (Required) D (Dependent) A (Advised) O (Optional) N (Not used)
Defined as mandatory in message/segment, must also be used here. Defined as conditional in message/segment, must be used according to this recommendation. Defined as conditional in message/segment, must be used under certain circumstances according to this recommendation. Defined as conditional in message/segment, recommended to be used according to this recommendation. Defined as conditional in message/segment, may be used according to this recommendation. Defined as conditional in message/segment, should not be used according to this recommendation. This value is specified in this MIG if the object is not to be used.
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•
X (Not for use)
Defined as conditional in message/segment, should not be used according to this recommendation. Receiving of such information should result in application error. This value is not used in this MIG.
A conditional segment or segment group can be omitted in the subset even if the segment group contains mandatory segments at a lower level, or the conditional segment contains mandatory data element or composites. “+” before a segment tag, data element or a code value tells that this is a new element according to the EDIFACT D.96B directory. “*” before a segment tag, data element or a code value tells that this is a modified element according to the EDIFACT D.96B directory.
3.3 Representation of information
The various attributes are assigned a specific data type in the data model. Each data type is normally implemented in the message in a uniform manner. One item of information may, however, be represented in different ways in the message. The information should as far as possible be transmitted in coded form in data fields typically called “xxx, coded” or “xxx, identification”. Very often it will exists a data element “xxx” for the respective uncoded information. This data element will then contain a descriptive text of the coded data element if coded value is specified or supposed to be equivalent to a coded value if the code is unknown and therefore not given. These two data elements will therefore contain the same information. Additional free form text is normally represented using the FTX segment.
3.4 Length of data elements
The data model has not defined any maximum length for the attributes. However, the data elements in the EDIFACT message have a defined maximum length. Length of Code meaning is usually limited to 70 characters and sometimes less.
3.5 Coding scheme identification
A coding scheme identifier is normally needed to identify uniquely the coding scheme used for each coded data element. If there is a coding scheme to be used universally for this message, such as EDIFACT coding schemes, then the code list identifier can be left out. Otherwise the International coding scheme identifier (ICSI) should be used. Until commonly used coding schemes have been identified this way the coding scheme identifiers in this MIG should be used. The recommended International coding scheme identifier (ICSI) consisting 6 characters should be represented by a fixed value in data element 3055 and the ICSI in data element 1131. However, the data element 1131 currently only allows for 3 characters. It is to be expected that this data element will be extended to cater for all the 6 characters of the ICSI.
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3.6 Codes
The Specification contains partly examples of codes that may be used (an open list of codes) and partly a list of codes that should be used (a closed list of codes): Open list: An open list is identified with the text “Examples of codes for …”. The codes mentioned are only examples and also non-listed codes may be used. Use of non-listed codes need a mutually agreement between the parts. Closed list: This type of list is identified by the word “examples” not being present in the description of the data element and only the codes in the list should be used. This implementation guide is mainly based on the UN/EDIFACT directory, version D.96B, but in addition some unofficial code values are defined (often as Znn).
3.7 Other issues
In the segment DTM - Date/time/period the following notation is used:
CC YY = = Century Year Month Day Hour Minute Seconds.
MM = DD HH = =
MM = SS =
The letter “M” is used to indicate both month and minute. The meaning in each case will normally become clear from the context. For activities with obviously shorter time period than 100 year, and where it cannot be any doubt about the actual century it belongs to, time periods may be given without century information. In all activities with longer time periods (as birth date), century must be included.
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Edifact Message Implementation Guide for Diabetes Report Scope of the message
4 Scope of the message
4.1 Function
The EDIFACT message MEDDBS (Diabetes Report message) is to be sent from a general practitioner or from a hospital to a regional or national data collection point, to report clinical information on patients with diabetes.
4.2 Limitations
There are not any known actual limitations for the moment.
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Edifact Message Implementation Guide for Diabetes Report Message structure and content
5 Message structure and content
The mapping of the complete information content to this message is documented in Annex A. The subset used in this implementation guide is specified in section 5.3.
5.1 Message content
The message consists of the following main parts:
• • • • • • Information about the message itself Information about sending healthcare party Patient administrative information about one or more patients Information about clinical information Information about clinical investigation Information about treatment
The message is documented with the objects in the sequence they are encountered in the message. For each object the used segments are documented.
5.2 Message structure
A Diabetes Report message is a collection of diabetes surveillance data concerning one or more patients from a single healthcare party. The overall structure of the message is:
• • • One message only relates to one sending healthcare party. The message may contain information concerning one or more patient(s). For each patient there may be clinical information, clinical investigation(s) and/or treatment(s).
This message is designed to meet the requirements of the World Health Organisation (WHO) St Vincent declaration. The paper form, referred to as the Basic information sheet (BIS), covers symptom, treatment and related administrative information. This EDIFACT message supports exactly the information required in this form. Fields from the Basic information sheet are mapped into a very simple message structure. The table on the next consecutive pages expresses how the data fields in the Basic information sheet are mapped into various segment groups and individual segment elements in order to transmit the required information. The data fields are grouped according to the headings on the Basic information sheet. The set of data fields related to each heading is typically mapped into one segment group in the message. However, different sets can be mapped into the same segment group (although not the same occurrence of the segment group) such as Clinical information. To distinguish between each set of information, Clinical information is documented as Clinical information type 1, Clinical information type 2, etc. The same is done for Clinical investigation and Treatment. Different sets of data fields are mapped to the same segment group, but each set may use different segments and different data elements within the segment group or segment as shown in the table below. Segments not
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Edifact Message Implementation Guide for Diabetes Report Message structure and content
used for a specific data field is darkly shaded. For each data field the appropriate code value(s) are listed for each segment in use. The character "-" indicates that the segment is being used, but not this specific data element within it. Alternative code values are separated by "/". The EDIFACT data elements and code values listed in this table are not a complete list of all the segments and data elements to be used for the information interchange. If a single set of code value(s) is specified for several data fields in one set (see BIS category Quality of life and Management), only one of the actual data fields can be represented for one patient record. Maximum numbers of the occurrences of each segment group is also specified in the table. This means for example if all data fields in the basic sheet category “Education/Diab. Pat. Org.” is to be represented, 7 occurrences of the segment group 2 (Clinical information) including 7 occurrences of the segment CIN (Type of clinical information) is to be represented in the message. Table 1 lists all data fields in the Basic information sheet, but only data fields used in the Norwegian subset are fully described. The names of the remaining data fields are listed in light grey types followed by light grey shaded boxes.
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BIS category Basic patient data
Field # Message functional category / SG #/ Field max # Not supported in message 1 4 Patient identifier Treating physician BIS administrative details Country Centre address Centre ID Date of record Patient details Initials Date of birth Sex Clinical information type1 Type of diabetes Year of diagnosis Oral anti-diabetes drug since Insulin treated since Patient administrative details
2 3 5
ADR 3477 1
PNA 3035
DTM 2005
Z25 SG1/ 1 PDI 3499 PNA 3405 Z03 182 DTM 2005 329 SG2/ 1 1/2 CIN 6415 DBI CIN 6413 ID/NI/OT DTM 2005 900 901 902 QTY 6063
6, 7 8 9
10 11 12 13 Reasons for Consultation/ Admission
Pregnancies
14-15 Consultation/admission 16-22 Consultation/admission reason Clinical information type 2 23 24 25 26 27 Pregnancies - ending in last 12 months Number of normal pregnancies Number of miscarriages/ stillbirths Number of major malformations Number of perinatal deaths Clinical information type 3 SG2/ 1 Smoker No of cigs/per day Alcohol Alcohol: amounts Clinical information type 4 Self-monitoring Blood glucose/week Urine glucose/week
CIN 6415
CIN 6413
DTM 2005
QTY 6063
Risk factors 28 29 30 31 Self-monitoring 32 33 34
CIN 6415 RSK
CIN DTM 6413 2005 SM/ NSM
QTY 6063
SG2/ 1
CIN 6415 SMI
CIN 6413 PSM/NM
DTM 2005
QTY 6063 BGM
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Edifact Message Implementation Guide for Diabetes Report Message structure and content
BIS category Education/ Diab. pat. org.
Field # Message functional category / SG #/ Field max # Clinical information type 5 SG2/ 7 35 36 37 38 39 40 41 Healthy eating Foot care Complications Self-monitoring Hypoglycaemia Self-adjustment Member of a diabetes patient organisation Clinical investigation type 1 Weight Height Systolic blood pressure Diastolic blood pressure Blood glucose fasting HbA1 HbA1c Creatinine Microalbuminuria Proteinuria Cholesterol HDL-cholesterol Triglycerides Fasting method Clinical information type 6 Blindness Blindness occurred within last 12 months MI/CABG/Angloplasty MII within last 12 months Cerebral stroke Cerebral stroke within last 12 months End-stage renal failure End-stage renal failure in last 12 months Leg amputation above ankle Leg amp. above ankle in last 12 months Leg amp. below ankle Leg amp. below ankle in last 12 months
CIN 6415 DEI DEI DEI DEI DEI DEI DEI CCI 7059 CLI CLI CLI CLI CLI CLI CLI CLI CLI CLI CLI
CIN DTM 6413 2005 HE/NHE FC/NFC CP/NCP MS/ NMS HG/ NHG SA/NSA MB/ NMB CCI 7037 CIN 6413 BL/NBL ATT 9021 WET HT SY DS BG HBC CR MR CH HD TR DTM 2005
QTY 6063
Measurements 42 43 44 45 46 47 48 49 50 51 52 53 54 55 St. Vincent targets 56 57 58 59 60 61 62 63 64 65 66 67
SG3/ 11
RSL 6155 QTY 6063
SG2/ 5
CIN 6415 SVT
SVT SVT
MI/NMI ST/NST
SVT
ER/NER
SVT
LA/NLA
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BIS category Symptoms
Field # Message functional category / SG #/ Field max # Clinical information type 7 68 69 70 71 72 Postural hypertension Anginal chest pain Erectile impotence Peripheral neuropathy Leg claudication Clinical investigation type 2
CIN 6415
CIN 6413
DTM 2005
QTY 6063
Examinations (eyes) 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 Examinations (feet) 94 95 96 97 98 99 100 101 102 103 104 105 106
SG3/ 3
Eyes examination within last 12 months Cataract L Cataract R Photocoagulation L Photocoagulation R Retina seen L Retina seen R Maculopathy L Maculopathy R Retinopathy L Retinopathy R Non-proliferative retinopathy L Non-proliferative retinopathy R Pre-proliferative retinopathy L Pre-proliferative retinopathy R Proliferative retinopathy L Proliferative retinopathy R Advanced diabetes eye disease L Advanced diabetes eye disease R Visual acuity L Visual acuity R Clinical investigation type 3 SG3/ 5 Foot examination within 12 months Normal vibration sensitivity L Normal vibration sensitivity R Normal pinprick sensitivity L Normal pinprick sensitivity R Foot pulses present L Foot pulses present R Healed ulcer/gangrene L Healed ulcer/gangrene R Acute ulcer/gangrene L Acute ulcer/gangrene R Bypass/angioplasty L Bypass/angioplasty L
CCI 7059 CLE
CCI 7037 EL
ATT 9021
RSL 6155
CLE
PH
10/23
CLE
RT
10/23
CCI 7059 CLE CLE
CCI 7037 LT NV
ATT 9021
RSL 6155
10/23
CLE CLE CLE
FP HL AU
10/23 10/23 10/23
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Edifact Message Implementation Guide for Diabetes Report Message structure and content
BIS category Quality of life
Field # Message functional category / SG #/ Field max # Clinical information type 8 SG2/ 1 107 108 109 110 Hypoglaecimia Hyperglaecimia Sick leave Hospital days Treatment type 1 Diet only - up to now Diet only - from now on Biguanides - from date Biguanides - up to now Biguanides - from now on Sulphonylureas - from date Sulphonylureas - up to now Sulphonylureas - from now on Glucosidase - since date Glucosidase - up to now Glucosidase - from now on Insulin pump - up to now Insulin pump - from now on Other treatment - up to now Other treatment- from now on Treatment type 3
CIN 6415 EM
CIN 6413 -
DTM 2005
QTY 6063 HYO SL
Management 111 112 113 114 115 116 117 118 119 120 121 124 125 126 127
SG4/ 4
CLI 9437 DT
IMD 7009
DTM 2005
QTY 6063
ATT 9021 FR
DR
BG
194
FR
DR
SU
194
FR
DR
GL
194
FR
SG4/ 1
CLI 9437
IMD 7009
DTM 2005
QTY 6063
ATT 9021
122 123 Additional treatment 128 129 130 131 132 133 134 135 136 137 138 139 140 141
Number of insulin injections per day - up to now Number of insulin injecti ons per day - from now on Treatment type 2 SG4/ 3 Hypertension - up to now Hypertension - from now on Cardiac failure - up to now Cardiac failure - from now on Isch. heart disease - up to now Isch. heart disease - from now on Dyslipidaemia - up to now Dyslipidaemia - from now on Nephropathy - up to now Nephropathy - from now on Neuropathy - up to now Neuropathy - from now on Other - up to now Other - from now on
II CLI 9437 IMD 7009 HY DTM 2005
NI QTY 6063
FR ATT 9021 FR
-
IH
FR
-
DL
FR
Table 1 Data fields in BIS mapped to MEDDBS data elements
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5.3 Message subset
The message subset is defined in order to satisfy the national requirements for transfer of diabetes reports from a healthcare party to a hospital or a regional/national data collection point. The information content in Norway is reduced compared to the information content of the Basic information sheet. The subset is documented in table 2, and the Norwegian reporting scheme is shown in Annex D. Each segment group uses different segments and the expanded message is described in table 3.
Information about the message: UNH BGM DTM PNA ADR Patient administrative information: SG1 PDI PNA DTM Clinical information: SG2 CIN O 16 M 1 Type of clinical information Type of diabetes Diabetes educational information Complications (Quality of life) Risks Self-monitoring St. Vincent targets Year of diagnosis Oral anti-diabetic drug since Insulin since Blood/glucose/week Hypoglycaemia episodes Days of sick leave M1 M M R M 1 1 11 1 Message reference number Message type Message name Date/time message generated ID of diabetes centre Country Other address details of this reporting centre
M M R M
999 1 Patient administrative sex 2 Patient initials 1 2 Issue date/time of this diabetes report Year of birth
DTM
D 3
QTY
D 2
Clinical investigation: SG3 CCI ATT RSL Treatment: SG4 CLI IMD DTM QTY ATT UNT Table 2 Norwegian subset of the segment mapping O M D D D R M 8 1 1 1 1 1 1 Type of treatment Treatment detail Start treatment Number of injections Period Message trailer O 19 M 1 D 1 D 1 Clinical examination Clinical investigation Type of investigation Investigation measurements
1 The segment PNA in message start is added in the Norwegian subset compared to the MEDDBS proposal from February 1997. 2 The segment PNA in segment group 1 is added in the Norwegian subset compared to the MEDDBS proposal from February 1997.
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Edifact Message Implementation Guide for Diabetes Report Message structure and content
Table 2 below shows the expanded message and the actual use according to the information in the Basic information sheet. The field number (F002, F003 etc.) in the Basic information sheet described in section 5.2 is specified to the left of the segment description where appropriate. The table shows how the segments and the segment groups are to be used for the different type of information (as clinical investigation type 1, type 2, etc.). The number of occurrences for each segment and segment group is reflecting the use for different information types and will deviate according to the complete subset described in Table 2. All segments will not be used for all types of information. The table lists the use of the message with respect to the complete Basic Information sheet, but the information not used in the Norwegian subset is listed in light grey types, and these segments are listed according to the complete message described in annex A.
Information about the message: UNH BGM DTM PNA ADR M1 M M R M 1 1 1 1 Message reference number Message type Message name Date/time message generated ID of diabetes centre Country Other address details of this reporting centre
F003 F002
3
Patient administrative information: F009 F006 F007 F005 F008 SG1 PDI PNA DTM PAS IDE Clinical information type 1: F010 F011 F012 F013 SG2 CIN DTM O 1 M 1 O 3 Type of clinical information Year of diagnosis Oral anti-diabetic drug since Insulin since Related numeric information Within/not within 12 months M 999 M 1 Patient administrative sex R 1 Patient initials M 2 C 9 C 1 Issue date/time of this diabetes report Year of birth Attendance type and reason for attendance Identification for this patient record
QTY C 9 ATT C 1 Clinical information type 2 (pregnancies): SG2 C 99 CIN M 1 DTM C 9 QTY C 4 ATT C 1
Type of clinical information Associated date Related numeric information Within/not within 12 months
3 F002, F003, etc. refers to the field number in the Basic Information Sheet for implementation of the St. Vincent declaration.
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Clinical information type 3 (risk factors): SG2 O 1 F028 CIN M 1 Type of clinical information (Risks) DTM C 9 Associated date QTY C 9 Related numeric information ATT C 1 Within/not within 12 months Clinical information type 4 (self-monitoring): SG2 O 1 F032 CIN M 1 Type of clinical information (Self-monitoring) DTM C 9 Associated date F033 QTY O 1 Blood glucose/week ATT C 1 Within/not within 12 months Clinical information type 5 (education / diab. pat. org.): SG2 O 7 F035 CIN M 1 Type of clin. information (diabetes information) F036 F037 F038 F039 F040 F041 DTM C 9 Associated date QTY C 9 Related numeric information ATT C 1 Within/not within 12 months Clinical information type 6 (St. Vincent targets): SG2 O 5 F056 CIN M 1 Type of clinical information (St. Vincent targets) F058 F060 F062 F064 DTM C 9 Associated date QTY C 9 Related numeric information ATT O 1 Within/not within 12 months Clinical information type 7 (symptoms): SG2 C 99 CIN M 1 Type of clinical information DTM C 9 Associated date QTY C 9 Related numeric information ATT C 1 Within/not within 12 months Clinical information type 8 (quality of life): SG2 O 1 CIN M 1 Type of clinical information (complications) DTM C 9 Associated date F107 QTY O 2 Hypoglycaemia F109 Sick leave ATT C 1 Within/not within 12 months
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Clinical investigation type 1 (measurements): SG3 O 11 CCI M 1 Clinical investigation ATT O 1 Investigation type F042 RSL O 1 Investigation measurement values F043 F044 F045 F046 F048 F049 F050 F052 F053 F054 Clinical investigation type 2 (examinations - eyes): SG3 O 3 F073 CCI M 1 Clinical examination ATT C 1 F076 RSL D 1 Investigation measurement values F082 Clinical investigation type 3 (examinations - feet): SG3 O 5 F094 CCI M 1 Clinical examination ATT C 1 F095 RSL D 1 Investigation measurement values F099 F101 F103 Treatment type 1 (management): SG4 O 4 CLI M 1 Type of treatment F115 IMD D 1 Treatment detail F118 F121 DTM D 1 Start treatment QTY C 1 Quantity administered F112 ATT R 1 Period F115 F118 F121 Treatment type 2 (additional treatment): SG4 O 3 F129 CLI M 1 Type of treatment F133 F135 IMD R 1 Start treatment DTM C 1 Associated date QTY C 1 Quantity administered ATT R 1 Period
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Treatment type 3 (insulin injections): SG4 CLI IMD DTM F123 QTY ATT Security information: SG5 AUT DTM UNT Table 3 Expanded message structure
O M C C R R C M C M
1 1 9 1 1 1 9 1 9 1
Type of treatment Treatment detail Associated date Number of injections Period
Authentication result Date/time for validity of authentication Message trailer
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SG001 - UNH
Edifact Message Implementation Guide for Diabetes Report Patient administrative information
6 Detailed message content
6.1 Message header
The attributes below are mapped
UNH
Occurrence: Function: Usage: Comments: Example:
MESSAGE HEADER
M1 A service segment starting and uniquely identifying the message.
⇓
UNH+nnn+MEDDBS:0:96B:RT:NO3010'
Format Use Description an..14 M Unique identifier for the message. Normally generated by the EDI interface application.
Message ref. number Message type
Tag Data element name 0062 MESSAGE REFERENCE NUMBER S009 MESSAGE IDENTIFIER 0065 Message type identifier 0052 Message version number
M an..6 an..3 M M Message type identifier: +MEDDBS *Diabetes reporting message Version of message type. This implementation is based upon D.96B (= "962"). +0 *Status 0 Message type release number. This implementation is based upon the status 0 version. +96B *Based on 96B directory Code to identify the agency controlling this message type. RT UN/ECE/TRADE/WP.4/GE.1/EDIFACT Rapporteurs Teams Identification of implementation. This is specified using a three character ID of the agency (= "COC" for CoCo) and 3 digits for identifying the version (001 identifies version 0.1 of the MIG, 010 identifies version 1.0 etc.). Not in use Not in use
0054 Message release number
an..3
M
0051 Controlling agency
an..2
M
0057 Association assigned code
an..6
R
0068 COMMON ACCESS an..35 REFERENCE S010 STATUS OF THE TRANSFER
N N
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SG001 - DTM
The attributes below are mapped
BGM
Occurrence: Function: Usage: Comments: Example:
BEGINNING OF MESSAGE
M1 To indicate the type and function of a message and to transmit the identification of the message.
⇓
BGM+D01'
Tag Data element name Format Use Description C002 DOCUMENT/MESSAGE NAME R
Message name
1001 Document/message name, coded 1131 Code list qualifier
an..3 an..3
R N N N N
Code for type of document: +D01 *Diabetes report Not in use Not in use Not in use Not in use Not in use Not in use
3055 Code list responsible agency, an..3 coded 1000 Document/message name an..35 C106 DOCUMENT/MESSAGE IDENTIFICATION 1225 MESSAGE FUNCTION, CODED 4343 RESPONSE TYPE, CODED
an..3 an..3
N N
The attributes below are mapped
DTM
Occurrence: Function: Usage: Comments: Example:
DATE/TIME/PERIOD
M1 To specify date and/or time relating to the message, such as the date and time the message is generated. To specify date/time message is generated.
⇓
DTM+137:961108161000:202'
Format Use Description M an..3 an..35 M R Type of date/time: 137 Document/message date/time Date/time message is generated by application.
Tag Data element name C507 DATE/TIME/PERIOD 2005 Date/time/period qualifier
Date/time message generated
2380 Date/time/period
2379 Date/time/period format qualifier
an..3
R
Format for date/time: 202 YYMMDDHHMMSS
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Edifact Message Implementation Guide for Diabetes Report Patient administrative information
The attributes below are mapped
PNA
Occurrence: Function: Usage: Comments: Example:
Party name
R1 To specify information necessary to establish the identity of the reporting healthcare party.
⇓
PNA+Z25++00004712015015A'
Format Use Description an..3 M Role of healthcare party: +Z25 *Reporting party N Not in use R an..35 M The identification number is cccccckkkkppppx where cccccc specifies nationality ('000047' for Norway), kkkk specifies community, pppp specifies the local postal code and x specifies the centre: numeric for hospitals and alphabetic for GPs. Not in use Not in use Not in use Not in use Not in use Not in use Not in use Not in use Not in use
Tag Data element name 3035 PARTY QUALIFIER C206 IDENTIFICATION NUMBER C082 PARTY IDENTIFICATION DETAILS 3039 Party id. identification
Centre ID
1131 Code list qualifier 3055 Code list responsible agency, coded 3403 NAME TYPE, CODED 3397 NAME STATUS, CODED C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS
an..3 an..3 an..3 an..3
N N N N N N N N N
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Edifact Message Implementation Guide for Diabetes Report Patient administrative information
SG001 - ADR
The attributes below are mapped
ADR
Occurrence: Function: Usage: Comments: Example:
ADDRESS
M1 To specify an address of a healthcare party.
⇓
ADR++1:Main street+Oslo+0501+NO'
Format Use Description N Not in use C an..3 an..70 an..70 an..70 an..70 an..70 an..35 an..9 an..3 M M N N N N A A R N N Code for address format: 1 Street name followed by number Address of report unit. Not in use Not in use Not in use Not in use Name of city or local post office. Postal code. Code for country. Not in use Not in use
Tag Data element name C817 ADDRESS USAGE C090 ADDRESS DETAILS 3477 Address format, coded
Centre address
3286 Address component 3286 Address component 3286 Address component 3286 Address component 3286 Address component
Name of city Postal code Country
3164 CITY NAME 3251 POSTCODE IDENTIFICATION 3207 COUNTRY, CODED C819 COUNTRY SUB-ENTITY DETAILS C517 LOCATION IDENTIFICATION
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SG001 - PDI
Edifact Message Implementation Guide for Diabetes Report Patient administrative information
6.2 Message body
SG001
Occurrence: Function: Usage: Comments:
PATIENT ADMINISTRATIVE INFORMATION
M 999 A group of segments to specify information about a person and possibly this person's contact with healthcare.
The following segments and/or segment groups are included:
Tag PDI PNA DTM 002 Name PERSON DEMOGRAPHIC INFORMATION Party name DATE/TIME/PERIOD CLINICAL INFORMATION ITEM Status M C M C Rep 1 1 2 16 Use M R M O Description To specify the sex of the patient. A segment to provide initials of patient. A segment to specify date and/or time related to the person and the report. This segment group contains clinical information about the patient such as medical history, investigation results, medication records or allergies. A group of segments for specifying a clinical investigation result item and the clinical investigation itself. A group of segments to describe a treatment.
003
CLINICAL INVESTIGATION
C
19
O
004
TREATMENT
C
6
O
The attributes below are mapped
PDI
Occurrence: Function: Usage: Comments: Example:
PERSON DEMOGRAPHIC INFORMATION
M1 To specify the sex of the patient.
⇓
PDI+1'
Format Use Description an..3 R Code for the sex of the person: +1 *Male +2 *Female N N Not in use Not in use
Patient administrative sex
Tag Data element name 3499 SEX, CODED
C085 MARITAL STATUS DETAILS C101 RELIGION DETAILS
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Edifact Message Implementation Guide for Diabetes Report Patient administrative information
SG001 - PNA
The attributes below are mapped
PNA
Occurrence: Function: Usage: Comments: Example:
Party name
R1 A segment to provide initials of patient.
⇓
PNA+LK+++++Z03:AS'
Format Use Description an..3 M Code for role of party: +LK *Patient N Not in use N an..3 an..3 N N R an..3 an..70 an..3 an..3 M R N N N N N N Specification of name component: +Z03 *Initials First and last initials of patient name. Not in use Not in use Not in use Not in use Not in use Not in use Not in use Not in use Not in use
Tag Data element name 3035 PARTY QUALIFIER C206 IDENTIFICATION NUMBER C082 PARTY IDENTIFICATION DETAILS 3403 NAME TYPE, CODED 3397 NAME STATUS, CODED C816 NAME COMPONENT DETAILS 3405 Name component qualifier
Patient initials
3398 Name component 3401 Name component status, coded 3295 Name component original representation, coded C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS C816 NAME COMPONENT DETAILS
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SG001 - DTM
Edifact Message Implementation Guide for Diabetes Report Patient administrative information
The attributes below are mapped
DTM
Occurrence: Function: Usage: Comments:
DATE/TIME/PERIOD
M2 A segment to specify date and/or time related to the person and the report.
⇓
Œ •
Date format 610 is to be used for date of birth. To be used for issue date/time of report
Example:
DTM+329:1934:602'
Format Use Description M an..3 M Type of date/time: 182 Issue date 329 Birth date/time Date of birth of person (year and month only). Issue date/time of report.Œ
Tag Data element name C507 DATE/TIME/PERIOD 2005 Date/time/period qualifier
Year of birth Issue date/time of report
2380 Date/time/period
an..35
R
2379 Date/time/period format qualifier
an..3
R
Format for date/time: 201• YYMMDDHHMM 602 CCYY 610 CCYYMM
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Edifact Message Implementation Guide for Diabetes Report Clinical information item
SG002 -
SG002
Occurrence: Function:
CLINICAL INFORMATION ITEM
O 16 This segment group contains clinical information about the patient such as medical history, investigation results, medication records or allergies. Each occurrence of this segment group provides information concerning one single clinical information type according to information given in the Basic sheet information. Different types of clinical information types may have different occurrences of this segment group, and different segments may be present for different types of information. O16 is the maximum total occurrences of this segment group.
Usage:
Comments:
The following segments and/or segment groups are included:
Tag CIN DTM QTY Name CLINICAL INFORMATION DATE/TIME/PERIOD QUANTITY Status M C C Rep 1 3 2 Use M D D Description To specify type of clinical information and to describe the actual clinical information. A segment to specify year of diagnosis and for start of antidiabetic treatment. A segment to specify a quantity related to clinical information.
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SG002 - CIN
Edifact Message Implementation Guide for Diabetes Report Clinical information item
The attributes below are mapped
CIN
Occurrence: Function: Usage: Comments: Example:
CLINICAL INFORMATION
M1 To specify type of clinical information and to describe the actual clinical information. Data element C836 is not used if code for type of clinical information is "EM" in 6415.
⇓
CIN+DBI+OT'
Format Use Description an..3 M Codes for type of clinical information: +DBI *Diabetes information +DEI *Diabetic education information +EM *Emergencies +RSK *Risks +SMI *Self-monitoring information +SVT *St. Vincent's targets D an..17 R Code for type of diabetes, risks, self-monitoring information, diabetic education information, quality of life and St. Vincent targets: +BL *Blindness +CP *Informed about complications +ER *End-stage renal failure +FC *Informed about foot care +HE *Informed about healthy eating +HG *Informed about hypo-glycaemia +ID *IDDM +LA *Leg amputation above ankle +MB *Member of diabetes patient organisation +MI *MI/CABG/Angioplasty +MS *Informed about self-monitoring +NBL *No blindness +NCP *Not informed about possible complications +NER *No end-stage renal failure +NFC *Not informed about foot care +NHE *Not informed about healthy eating +NHG *Not informed about hypo-glycaemia +NI *NIDDM +NLA *No leg amputation above ankle +NM *Patient does not self-monitor +NMB *Not member of diabetes patient organisation +NMI *No MI/CABG/Angioplasty +NMS *Not informed about self-monitoring +NSA *Not informed about self-adjustment +NSM *Non-smoker +NST *No cerebral stroke +OT *Other type of diabetes +PSM *Patient self-monitors +SA *Informed about self-adjustment +SM *Smoker +ST *Cerebral stroke Not in use Not in use Not in use Not in use
Type of clinical information
Tag Data element name 6415 CLINICAL INFORMATION QUALIFIER
Type of diabetes Risks Selfmonitoring Complications Diabetes educational information St. Vincent targets
C836 CLINICAL INFORMATION DETAILS 6413 Clinical information identification
1131 Code list qualifier
an..3
N N N N
3055 Code list responsible agency, an..3 coded 6412 Clinical information an..70 C837 CERTAINTY DETAILS
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Edifact Message Implementation Guide for Diabetes Report Clinical information item
SG002 - DTM
The attributes below are mapped
DTM
Occurrence: Function: Usage: Comments: Example:
DATE/TIME/PERIOD
D3 A segment to specify year of diagnosis and for start of antidiabetic treatment. This segment is only to be used in connection with type of diabetes (CIN with code "DBI" in 6415).
⇓
DTM+900:1975:602'
Format Use Description M an..3 M Type of date/time: +900 *Year of diagnosis +901 *Oral antidiabetes drug since +902 *Insulin since Year of diagnosis. Year for start of oral antidiabetic drug.
Tag Data element name C507 DATE/TIME/PERIOD 2005 Date/time/period qualifier
Year of diagnosis Oral antidiabetic drug since Insulin since
2380 Date/time/period
an..35
R
2379 Date/time/period format qualifier
an..3
R
Format for date/time: 602 CCYY
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SG002 - QTY
Edifact Message Implementation Guide for Diabetes Report Clinical information item
The attributes below are mapped
QTY
Occurrence: Function: Usage: Comments: Example:
QUANTITY
D2 A segment to specify a quantity related to clinical information. This segment is only to be used in connection with self-monitoring (CIN with code "SMI" in 6415) and emergencies (CIN with code "EM" in 6415).
⇓
QTY+BGM:1'
Format Use Description M an..3 M Code for type of quantity: +BGM *Blood glucose measurements +HYO *Hypoglycaemia episodes +SL *Days of sick leave To specify the number of blood glucose measurements per week. To specify the number of hypoglycaemia episodes. To specify the days of sick leave.
Tag Data element name C186 QUANTITY DETAILS 6063 Quantity qualifier
Blood glucose/ week Hypoglycaemi a episodes Days of sick leave
6060 Quantity
n..15
M
6411 Measure unit qualifier
an..3
N
Not in use
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Edifact Message Implementation Guide for Diabetes Report Clinical investigation
SG003 -
SG003
Occurrence: Function: Usage:
CLINICAL INVESTIGATION
O 19 A group of segments for specifying a clinical investigation result item and the clinical investigation itself. Each occurrence of this segment group provides information concerning one single clinical investigation type according to information given in the Basic sheet information. Different types of clinical investigation types may have different occurrences of this segment group, and different segments may be present for different types of information. O19 is the maximum total occurrences of this segment group.
Comments:
The following segments and/or segment groups are included:
Tag CCI ATT RSL Name CHARACTERISTIC/CLASS ID ATTRIBUTE RESULT Status M C C Rep 1 1 1 Use M D D Description A segment to specify the type of investigation as well as certain results of the investigation. A segment to specify an investigation. To specify a clinical investigation result item.
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SG003 - CCI
Edifact Message Implementation Guide for Diabetes Report Clinical investigation
The attributes below are mapped
CCI
Occurrence: Function: Usage: Comments: Example:
CHARACTERISTIC/CLASS ID
M1 A segment to specify the type of investigation as well as certain results of the investigation.
⇓
CCI+CLE++PH'
Format Use Description an..3 R Examples of codes for type of property: +CLE *Clinical examination +CLI *Clinical investigation N Not in use D an..17 M Code for specification of the investigation or the result: +AU *Acute ulcer/gangrene +EL *Eyes examined in last 12 months +FP *Foot pulses present +HL *Healed ulcer/gangrene +LT *Feet examined in last 12 months +NV *Normal vibration sensitivity +PH *Photocoagulation +RT *Retinopathy Not in use Not in use Not in use Not in use Not in use
Tag Data element name 7059 PROPERTY CLASS, CODED
C502 MEASUREMENT DETAILS C240 PRODUCT CHARACTERISTIC
Clinical examination Clinical investigation
7037 Characteristic identification
1131 Code list qualifier
an..3
N N N N N
3055 Code list responsible agency, an..3 coded 7036 Characteristic an..35 7036 Characteristic 4051 CHARACTERISTIC RELEVANCE, CODED an..35 an..3
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Edifact Message Implementation Guide for Diabetes Report Clinical investigation
SG003 - ATT
The attributes below are mapped
ATT
Occurrence: Function: Usage: Comments: Example:
ATTRIBUTE
D1 A segment to specify an investigation. This segment is only to be used in connection with clinical investigation (CCI with code "CLI" in 7059).
⇓
ATT+IT+BG'
Format Use Description an..3 M Code for type of attribute: +IT *Investigation type R an..3 M Code for type of investigation: +BG *Blood glucose fasting +CH *Cholesterol +CR *Creatinine +DS *Diastolic blood pressure +HBC *HbA1c +HD *HDL-cholesterol +HT *Height +MR *Microalbuminuria +SY *Systolic blood pressure +TR *Triglycerides +WET *Weight Not in use Not in use Not in use
Tag Data element name 9017 ATTRIBUTE FUNCTION QUALIFIER C955 ATTRIBUTE TYPE
Type of investigation
9021 Attribute type, coded
1131 Code list qualifier 3055 Code list responsible agency, coded C956 ATTRIBUTE DETAILS
an..3 an..3
N N N
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SG003 - RSL
Edifact Message Implementation Guide for Diabetes Report Clinical investigation
The attributes below are mapped
RSL
Occurrence: Function: Usage: Comments:
RESULT
D1 To specify a clinical investigation result item. The result can be specified in the RSL segment or in another segment. Œ • Only to be used if CCI has the value "CLI" in 7059. Only to be used if CCI not has the value "CLE" in 7059.
⇓
Example:
RSL+IV++5,5'
Format Use Description an..3 M Code for type of result: +IV *Investigation result an..3 N Not in use R an..18 D The result of a laboratory or clinical investigation.Œ
Tag Data element name 6087 RESULT QUALIFIER 6077 RESULT TYPE, CODED C831 RESULT DETAILS
Investigation measurement value Present / Not present
6314 Measurement value
6321 Measurement significance, coded 6155 Measurement attribute identification 1131 Code list qualifier
an..3 an..17
N D
Not in use Codes for coded measurement value:• 10 Present 23 Absent Not in use Not in use Not in use Not in use Not in use Not in use
an..3
N N N N N
3055 Code list responsible agency, an..3 coded 6154 Measurement attribute an..70 C831 RESULT DETAILS C848 MEASUREMENT UNIT DETAILS 6079 RESULT NORMALCY INDICATOR, CODED
an..3
N
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Edifact Message Implementation Guide for Diabetes Report Treatment
SG004 - CLI
SG004
Occurrence: Function: Usage:
TREATMENT
O8 A group of segments to describe a treatment. Each occurrence of this segment group provides information concerning one single treatment type according to information given in the Basic sheet information. Different types of treatments may have different occurrences of this segment group, and different segments may be present for different types of information. O 6 is the maximum total occurrences of this segment group.
Comments:
The following segments and/or segment groups are included:
Tag CLI IMD DTM QTY ATT Name CLINICAL INTERVENTION ITEM DESCRIPTION DATE/TIME/PERIOD QUANTITY ATTRIBUTE Status M C C C C Rep 1 1 1 1 1 Use M D D D R Description To specify a clinical intervention. A segment to identify a medicinal product item. A segment to specify a date related to the treatment. A segment to specify a quantity related to the treatment. A segment to specify a period of treatment.
The attributes below are mapped
CLI
Occurrence: Function: Usage: Comments: Example:
CLINICAL INTERVENTION
M1 To specify a clinical intervention.
⇓
CLI+DM+DR'
Format Use Description an..3 M Code for type of procedure: +DM *Diabetic management D an..17 A Code for type of treatment: +DR *Drug +DT *Diet +II *Insulin injections Not in use Not in use Not in use
Type of treatment
Tag Data element name 9441 CLINICAL INTERVENTION QUALIFIER C828 CLINICAL INTERVENTION DETAILS 9437 Clinical intervention identification
1131 Code list qualifier
an..3
N N N
3055 Code list responsible agency, an..3 coded 9436 Clinical intervention an..70
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SG004 - DTM
Edifact Message Implementation Guide for Diabetes Report Treatment
The attributes below are mapped
IMD
Occurrence: Function: Usage: Comments: Example:
ITEM DESCRIPTION
D1 A segment to identify a medicinal product item. This segment is only to be used in connection with treatment type 1 (only with CLI with code "DR" in 9437) or treatment type 2.
⇓
IMD+++BG'
Format Use Description an..3 N Not in use an..3 N R an..17 A Code for treatment: +BG *Biguanides +DL *Dyslipaemia +GL *Glucosidase inhibitor +HY *Hypertension +IH *Ischemic heart disease +SU *Sulphonureas Not in use Not in use Not in use Not in use Not in use Not in use Not in use
Tag Data element name 7077 ITEM DESCRIPTION TYPE, CODED 7081 ITEM CHARACTERISTIC, CODED C273 ITEM DESCRIPTION
Treatment detail
7009 Item description identification
1131 Code list qualifier
an..3
N N N N N N
3055 Code list responsible agency, an..3 coded 7008 Item description an..35 7008 Item description 3453 Language, coded 7383 SURFACE/LAYER INDICATOR, CODED an..35 an..3 an..3
The attributes below are mapped
DTM
Occurrence: Function: Usage: Comments: Example:
DATE/TIME/PERIOD
D1 A segment to specify a date related to the treatment. This segment is only to be used in connection with treatment type 1 with drug (CLI with code "DR" in 9437).
⇓
DTM+194:1985:602'
Format Use Description M an..3 an..35 an..3 M R R Type of date/time: 194 Start date/time Start date for actual treatment. Format for date/time: 602 CCYY
Tag Data element name C507 DATE/TIME/PERIOD 2005 Date/time/period qualifier
Start treatment
2380 Date/time/period 2379 Date/time/period format qualifier
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Edifact Message Implementation Guide for Diabetes Report Treatment
SG004 - ATT
The attributes below are mapped
QTY
Occurrence: Function: Usage: Comments: Example:
QUANTITY
D1 A segment to specify a quantity related to the treatment. Only to be used in connection with insulin injections.
⇓
QTY+NI:2'
Format Use Description M an..3 n..15 an..3 M M N Code for type of quantity: +NI *Number of injections Number of injections per day. Not in use
Tag Data element name C186 QUANTITY DETAILS 6063 Quantity qualifier
Number of injections
6060 Quantity 6411 Measure unit qualifier
The attributes below are mapped
ATT
Occurrence: Function: Usage: Comments: Example:
ATTRIBUTE
R1 A segment to specify a period of treatment.
⇓
ATT+PD+FR'
Format Use Description an..3 M Code for type of information: +PD *Period R an..3 an..3 an..3 M N N N Code for type of period of treatment: +FR *Management given from now on Not in use Not in use Not in use
Tag Data element name 9017 ATTRIBUTE FUNCTION QUALIFIER C955 ATTRIBUTE TYPE
Period
9021 Attribute type, coded 1131 Code list qualifier 3055 Code list responsible agency, coded C956 ATTRIBUTE DETAILS
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SG004 - UNT
Edifact Message Implementation Guide for Diabetes Report Message trailer
6.3 Message trailer
The attributes below are mapped
UNT
Occurrence: Function: Usage: Comments: Example:
MESSAGE TRAILER
M1 To end and check the completeness of a message.
⇓
UNT+34+nnn'
Format Use Description n..6 M Number of segments in the message including UNH and UNT. an..14 M Sender's unique message identifier identical to data element 0062 in UNH.
Tag Data element name 0074 NUMBER OF SEGMENTS IN THE MESSAGE 0062 MESSAGE REFERENCE NUMBER
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Annex A
Edifact Message Implementation Guide for Diabetes Report Segment Mapping MEDDBS
Annex A
Segment Mapping MEDDBS
Information about the message: UNH BGM DTM PNA ADR Patient administrative information: SG1 PDI PNA DTM PAS IDE Clinical information: SG2 CIN DTM QTY ATT Clinical investigation: SG3 CCI ATT RSL Treatment: SG4 CLI IMD DTM QTY ATT Security information: SG5 AUT DTM UNT C M C M 9 1 9 1 Authentication result Date/time for validity of authentication Message trailer C M C C C C 99 1 9 1 1 9 Treatment Treatment detail Associated date Quantity administered Period C M C C 99 1 1 1 Investigation description Investigation measurement values C M C C C 99 1 9 9 1 Type of clinical information Associated date Related numeric information Within/not within 12 months M1 M1 M9 C 1 M1 Message reference number Message type Message name Message function Date/time message generated ID of diabetes centre Country Other address details of this reporting centre
M M C M
999 1 Patient administrative sex 1 Patient initials 2 Issue date/time of this diabetes report Date of birth C 9 Attendance type and reason for attendance C 1 Identification for this patient record
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Annex B
Edifact Message Implementation Guide for Diabetes Report Message Examples
Annex B
Message Examples
One diabetes report with information for one patient. If information concerning more than one patient is to be sent, segment group 1-4 is to be repeated. Occurrence in the table refers to the occurrence number of the actual segment. Type refers to: type of clinical information for segment group 2, Cn type of clinical investigation for segment group 3, In type of treatment for segment group 4, Tn
SG Occurrence H 1 Type MESSAGE COMMENTS Field no
1
1
2
1
C1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
C3 C4 C5
C6
C8
UNH+100003+MEDDBS:0:96B:RT:NO Start MEDDBS message according 3010' to Norwegian implementation version 1.0 BGM+D01' New Diabetes report message DTM+137:940617121000:202' Message generated date/time PNA+Z25++00004712015001A' Centre ID ADR++1:Main street+Oslo+0501+NO' Address and country PDI+1' Sex PNA+LK+++++Z03:NN' Patient initials DTM+329:193410:610' Year and month of birth DTM+182:9810282030:201' Issue date/time CIN+DBI+OT' Type of diabetes DTM+900:1975:602' Year of diagnosis DTM+901:1980:602' Start drug treatment DTM+902:1995:602' Start insulin treatment CIN+RSK+SM' Smoker CIN+SMI+PSM' Self-monitoring QTY+BGM:2' Blood glucose/week CIN+DEI+HE' Healthy eating CIN+DEI+FC' Foot care CIN+DEI+NCP' Complications CIN+DEI+MS' Self-monitoring CIN+DEI+HG' Hypoglycaemia CIN+DBI+SA' Self-adjustment CIN+DBI+MB' Member of a diabetes patient organisation CIN+SVT+NBL' Blindness CIN+SVT+MI' MI/CABG/ Angioplasty CIN+SVT+NST' Cerebral stroke CIN+SVT+NER' End-stage renal failure CIN+SVT+NLA' Leg amputation above ankle CIN+EM' Emergencies QTY+HYO:3' Hypoglycaemia QTY+SL:10' Sick leave
F003 F002 F009 F006, F007 F008 F005 F010 F011 F012 F013 F028 F032 F033 F035 F036 F037 F038 F039 F040 F041 F056 F058 F060 F062 F064 F107 F109
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Edifact Message Implementation Guide for Diabetes Report Message Examples
Annex B
3
1
I1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17 18 19
I2
CCI+CLI' ATT+IT+WET' RSL+IV++75' CCI+CLI' ATT+IT+HT' RSL+IV++168' CCI+CLI' ATT+IT+SY' RSL+IV++120' CCI+CLI' ATT+IT+DS' RSL+IV++80' CCI+CLI' ATT+IT+BG' RSL+IV++5,5' CCI+CLI' ATT+IT+HBC' RSL+IV++10,2' CCI+CLI' ATT+IT+CR' RSL+IV++1,2' CCI+CLI' ATT+IT+MR' RSL+IV++0,5' CCI+CLI' ATT+IT+CH' RSL+IV++5,5' CCI+CLI' ATT+IT+HD' RSL+IV++2,3' CCI+CLI' ATT+IT+TR' RSL+IV++1,4' CCI+CLE++EL' CCI+CLE++PH' RSL+IV++::10' CCI+CLE++RT' RSL+IV++::23' CCI+CLE++LT' CCI+CLE++NV' RSL+IV++::10' CCI+CLE++FP' RSL+IV++::10' CCI+CLE++HL' RSL+IV++::23' CCI+CLE++AU' RSL+IV++::23'
Weight F042 Height F043 Systolic blood pressure F044 Diastolic blood pressure F045 Blood glucose fasting F046 HbAlc F048 Creatinine F049 Microalbuminuria F050 Cholesterol F052 HDL-cholesterol F053 Triglycerides Eyes examination within last 12 months Photocoagulation Retinopathy F082 Foot examination within 12 months F094 Normal vibration sensitivity F095 Foot pulses present F099 Healed ulcer/gangrene F101 Acute ulcer/gangrene F103 F054 F073
F076
I3
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Annex B
Edifact Message Implementation Guide for Diabetes Report Message Examples
4
1
T1
2
T2
3
4
5
T3
CLI+DM+DR' IMD+++BG' DTM+194:1998:602' ATT+PD+FR' CLI+DM' IMD+++HY' ATT+PD+FR' CLI+DM' IMD+++IH' ATT+PD+FR' CLI+DM' IMD+++DL' ATT+PD+FR' CLI+DM+II' QTY+NI:1' ATT+PD+FR' UNT+95+100003'
Biguanides - from now on
F115
Hypertension - from now on
F129
Isch. heart disease - from now on
F133
Dyslipaemia - from now on
F135
Number of insulin injections per day - from now on Number of segments and message reference
F123
T
1
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Annex C
Edifact Message Implementation Guide for Diabetes Report Mapping of Objects
Annex C
Mapping of Objects
The table below specifies each object and respective attributes which are used in this specific implementation of the message.
Melding M1 Unique identifier for the message. Normally allocated by EDI interface an..14 application. an..6 an..3 Message type identifier: Code for type of document: Specification of usage
Message ref. number Message type Message name
M M M
UNH N/A 0062 UNH S009 0065 BGM C002 1001 DTM C507 2380
Date/time message generated M
Date/time message is generated by an..35 application. The identification number is cccccckkkkppppx where cccccc specifies nationality ('000047' for Norway), kkkk specifies community, pppp specifies the local postal code and x specifies the centre: numeric for an..35 hospitals and alphabetic for GPs. an..70 Address of report unit. an..35 Name of city or local post office. an..9 an..3 Postal code. Code for country.
Centre ID Centre address Name of city Postal code Country
M O O O M
PNA C082 3039 ADR C090 3286 ADR N/A 3164 ADR N/A 3251 ADR N/A 3207
Patient administrative information Patient administrative sex Patient initials Year of birth Issue date/time of report
M999 M M M M an..3 Code for the sex of the person: SG1 PDI N/A 3499 SG1 PNA C816 3398 Date format 610 is to be used for year of birth. SG1 DTM C507 2380 SG1 DTM C507 2380
an..70 First and last initials of patient name. Date of birth of person (year and month an..35 only). an..35 Issue date/time of report.
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Edifact Message Implementation Guide for Diabetes Report Mapping of Objects
Annex C
Clinical information item Type of clinical information Type of diabetes Risks Self-monitoring Complications Diabetes educational information St. Vincent targets Year of diagnosis Oral antidiabetic drug since Insulin since Blood glucose/ week Hypoglycaemia episodes Days of sick leave
O16 M D D D D D D D D D D D D an..3 an..17 Codes for type of clinical information:
Specification of usage SG2 CIN N/A 6415 SG2 CIN C836 6413 SG2 CIN C836 6413 SG2 CIN C836 6413 SG2 CIN C836 6413 Data element C836 is not SG2 CIN C836 6413 used if code for type of clinical information is “EM” SG2 CIN C836 6413 in 6415. SG2 DTM C507 2380 This segment is only to be SG2 DTM C507 2380 used in connection with type of diabetes (CIN with SG2 DTM C507 2380 code "DBI" in 6415).
Code for type of diabetes: an..17 Code for type of risks: Code for type of self-monitoring an..17 information: an..17 Code for type of quality of life. Code for type of diabetic education an..17 information. an..17 Code for type of St. Vincent targets: an..35 Year of diagnosis. an..35 Year for start of oral antidiabetic drug. an..35 Year for start of insulin treatment. To specify the number of blood glucose n..15 measurements per week.
This segment is only to be SG2 QTY C186 6060 used in connection with To specify the number of Hypoglycaemia self-monitoring (CIN with n..15 episodes. SG2 QTY C186 6060 code "SMI" in 6415) and emergencies (CIN w ith n..15 To specify the days of sick leave. SG2 QTY C186 6060 code "EM" in 6415).
Clinical investigation
O19 Code for specification of the investigation an..17 or the result:
Clinical examination Clinical investigation
D D
SG3 CCI C240 7037
Code for specification of the investigation Used for specification of the investigation or result SG3 CCI C240 7037 an..17 or the result: This segment is only to be used in connection with clinical investigation (CCI SG3 ATT C955 9021 with code "CLI" in 7059). Only to be used if CCI has the value "CLI" in 7059. SG3 RSL C831 6314 Only to be used if CCI not has the value "CLE" in 7059. SG3 RSL C831 6155
Type of investigation Investigation measurement value
D D
an..3
Code for type of investigation:
The result of a laboratory or clinical an..18 investigation.
Present / Not present
D
an..17 Codes for coded measurement value:
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Edifact Message Implementation Guide for Diabetes Report Mapping of Objects
Treatment Type of treatment
O8 O an..17 Code for type of treatment: SG4 CLI C828 9437 This segment is only to be used in connection with treatment type 1 (only with CLI with code "DR" in SG4 IMD C273 7009 9437) or treatment type 2. This segment is only to be used in connection with treatment type 1 with drug (CLI with code "DR" in SG4 DTM C507 2380 9437). Only to be used in connection with insulin SG4 QTY C186 6060 injections. SG4 ATT C955 9021
Treatment detail
O
an..17 Code for type of treatment:
Start treatment
D
an..35 Start date for actual treatment.
Number of injections Period
D M
n..15 Number of injections per day. an..3 Code for type of period of treatment:
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Edifact Message Implementation Guide for Diabetes Report Annex D
Report Schema
Annex D
Report Schema
The report schema (in Norwegian) used in Norway is given below.
Minimalt diabetes datasett
Felt kategori Felt beskrivelse Basisdata Praksis identifikasjon Dato for registrering Fødselsdato Kjønn Type diabetes Diagnose Tablettbehandling startet Insulinbehandling startet Risikofaktor Røyking Egenmåling Måler blodsukker selv Egenmålinger Opplæring Kost Fotstell Komplikasjoner Egenmåling Hypoglykemi Egenjustering Medlem NDF Målinger Vekt Høyde Systolisk BT Diastolisk BT Fastende blodsukker HbA1c Kreatinin Mikroalbuminuri Total kolesterol HDL kolesterol Triglyserider Utfylling 15 siffer Felt kategori St.Vincent mål Felt beskrivelse Blindhet Koronarsykdom Cerebrovaskulær hendelse Nyresvikt Amputasjon Øyelege siste 12 mnd Laserbehandling Retinopati Fotundersøkelse siste 12 mnd Normal vibrasjonssans Fotpuls tilstede Aktuelt sår Hypoglykemi Sykmelding Kost Biguanider Sulfonylurea Glucosidase inhibitor Insulinbehandling Blodtrykk Iscemisk hjertesykdom Dyslipidemi Utfylling J/N J/N J/N J/N J/N J/N J/N J/N J/N J/N J/N J/N Antall/år Antall dager/år J/N J/N J/N J/N Antall inj/dag J/N J/N J/N
M/K 1/2/3 Årstall Årstall Årstall J/N J/N Antall/uke J/N J/N J/N J/N J/N J/N J/N kg cm mmHg mmHG mmol/l % mmol/l µg/min mmol/l mmol/l mmol/l
Undersøkelser
Livskvalitet Behandling
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