Goal:

A goal refers to an objective to be achieved as a consequence of healthcare interventions applied to an individual. Goals are set in many areas of the healthcare system, and include educational, behavior modification, and clinical goals such as reduced discomfort, improved circulation. Goals are documented by a variety of healthcare professionals including physicians, nurses, and respiratory and other therapists. Goals are defined during patient visits and they may span one or multiple visits, encounters, or episodes of care.

Problem:

A problem of a given individual can be described by formal diagnosis coding systems (such as DRGs, NANDA Nursing Diagnosis, ICD9, DSM, etc.) or by other professional descriptions of healthcare issues affecting an individual. Problems can be short- or long-term in nature, chronic or acute, and have a status. In a longitudinal record, all problems may be of importance in the overall long-term care of an individual, and may undergo changes in status repeatedly. Problems are identified during patient visits, and may span multiple visits, encounters, or episodes of care.

Role:

A role refers to the function or responsibility assumed by a person in the context of a healthcare event. Role information documents a person's association with an identified healthcare activity. Examples include primary care provider, transcriptionist, reviewer, and consulting physician.

Clinical pathway:

A clinical pathway is a standardized plan of care against which progress towards health is measured. A clinical pathway is applied based upon the results of a patient assessment. A clinical pathway shows exact timing of all key patient care activities intended to achieve expected standard outcomes within designated time frames. A clinical pathway includes documentation of problems, expected outcomes/goals, and clinical interventions/orders.

Variance:

Variances are documented deviations, either positive or negative, from a pre-defined standard. Variances are documented against expected outcomes, orders, or the patient's progress in general.

Patient pre-admission or patient admission

A physician's office is scheduling a patient for admission to the hospital. The admitting diagnosis/problem list and admission information is sent by the physician's electronic information system to the hospital's Patient Administration system and longitudinal medical record. The trigger event identifies the message as an "add problem" or update patient medical information to the Patient Administration and medical record system.

Consultation

A consultation is requested for an individual. The information system generating the consultation triggers an unsolicited message containing the problem/diagnosis list that is transmitted to the consulting organization. Goals and various kinds of role information are included with the transmission. The trigger event identifies the message as an unchanged record.

Loading a clinical repository

Information from point of care, clinical practice management or ancillary systems regarding the creation or update of pathways, problems, diagnoses, or goals are communicated to the clinical repository. Message triggers from the departmental systems may indicate adding, correcting, deleting, or updating records maintained in the clinical data repository.

Communicating clinical pathways and multidisciplinary plans of care

The pathway is communicated between Quality Assurance, Point of Care Systems, Research Databases, and Clinical Order Entry Systems. A point of care information system triggers a linkage between a problem and a set of ordered interventions initiated by the clinical order entry system.

Examples of action code usage

A problem list and associated goals are generated in a Point of Care system. This transaction is broadcast through an interface engine that determines which systems in the organization require the event information and then forwards the messages appropriately. Each segment included in the original message contains the Action Code for ADD to signify an original message instance.

1. Upon subsequent review, it is determined that a role segment designates the wrong person as the transcribing clerk for a problem. After the information is changed in the originating system, a new message is sent to provide synchronization. The message includes the original PRB segment with the PRB-1 Action Code for UNCHANGED (to identify the problem for which the role is being changed). This code signifies that the segment is included for the purposes of hierarchical linkage identification and that none of the information contained in it has been changed. The accompanying role segment sent would include the role transcriber in ROL-3 Role, the correct person in ROL-4 Role Person, and the value for CORRECT in ROL-2 Action Code.

2. It is later decided that an additional goal must be added to a specific problem, and that an already existing goal that is currently supporting another problem should also be linked with this specific problem. The message would be constructed with the problem (PRB) segment for identification (the value for PRB-1 Action Code is UNCHANGED). The goal segment (GOL) for the additional goal would include GOL-1 Action Code for ADD. The goals already included with the problem list that need to be linked to this problem would have to be included on additional GOL segments with the GOL-1 Action Code for LINK.
   
   Once data regarding a Diagnosis/Problem or a Goal have been communicated to other systems, there are occasions on which the data may have to be amended.

3. New diagnoses/problems must be added to an individual's list. The Problem message is sent with the appropriate Problem Instance ID. All PRB segment(s) included in the message that contain the value for ADD in PRB-1 Action Code are processed as additions to the individual's problem list.

4. New goals are added to the individual's record. The Goal message is sent with the GOL segments indicating the value for ADD as GOL-1 Action Code in each segment occurrence.

5. Changes are made to the attributes of a goal. Examples include a change in the expected resolution date, a change in the life cycle status to reflect its successful conclusion, etc. The Goal message is sent with the appropriate GOL-4 Goal Instance ID. The GOL segments of the Goal message would include the value for UPDATE in GOL-1 Action Code.

6. A new goal is attached to a problem already in the repository (e.g., the goal of "education on diabetes" for an individual diagnosed with "insulin-dependent diabetes"). A problem message would be sent with the PRB segment including the PRB-4 Problem Instance ID for the diabetes problem, and with the value UNCHANGED in PRB-1 Action Code. The attached GOL segment for the education goal would accompany the message and contain the value ADD in its GOL-1 Action Code field.

7. A new diagnosis/problem is attached to a goal (e.g., a Goal is to "discharge an individual with intact skin." While the initial problem was "skin breakdown related to immobility," a new problem is "potential for skin breakdown related to draining wounds"). A Goal message would be sent with the GOL segment, including the GOL-4 Goal Instance ID for the discharge goal, and contain the value UNCHANGED in GOL-1 Action Code. The attached PRB segment identifying the new problem, "potential for skin breakdown related to draining wounds," would accompany this message and contain the value for ADD in PRB-1 Action Code.

Rule 1

The trigger event defines the action at the first level of the hierarchy, and should not be contradicted by either hierarchical linkages or segment action codes. Thus, a PC1 (problem add) event should only contain problem, goal, and role segments that have action codes ADD.

Figure 12-1. Table of allowable trigger event types and action codes

Trigger Event Types	Allowable Action Codes
xxx-Add	Top level action code must be ADD Dependent segment action code must be ADD (or NW for Order segments)
xxx-Update	Top level action code must be CORRECT, UPDATE, or UNCHANGED Dependent segment action codes - Any are allowed at the lower hierarchical levels
xxx-Delete	Top level action code must be DELETE Dependent segments' action codes must be DELETE

Rule 2

When using the segment action codes LINK and UNLINK, only those fields which are used to define a unique instance of the object are used. This action cannot be used to send changes and updates to the other fields of that segment.

Rule 3

In dependent segments ADD is the action code to use to establish the initial relationship between parent-child objects. The receiving system must be ready to handle multiple adds of the same object. An example is a Problem List of three (3) problems which is being sent. Attached to these problems are three (3) goals. Problem A has Goals 1 and 2 attached to it. Problem B has the same Goal 2 and a new Goal 3 attached to it. All of these will have the ADD action code in the segment, and when Problem B is transmitted with Goals 2 and 3, Goal 2 will have been previously transmitted with Problem A. The message construct would look like this:

MSH...

PID...

            PRB (Problem A)

                GOL (Goal 1)

                GOL (Goal 2)

            PRB (Problem B)

                GOL (Goal 2)

                GOL (Goal 3)

            PRB (Problem C) (No attached goals)

When two (or more) instances of the same problem or goal segment are present in a message both such segments must have identical values for all fields.

Rule 4

Remember that HL7 only provides for error messages at the message level. Thus, if the receiving system cannot process one segment, the entire message is going to be treated as an error (See Chapter 2).

Rule 5

The Problem, Goal, and Pathway messages integrate order segments as a method for establishing causal linkages. Linkages or relationships between orders, problems, goals, and pathways can therefore be presented in the Patient Care messages.

Orders referenced in Patient Care messages are used for linkage purposes only. Initiation and status changes to orders are accomplished by using dedicated messages defined in the Order Entry Chapter.

Rule 6

Order segments are sent with Problem and Goal segments in order to establish a linkage between them, NOT to communicate new orders or changes to those orders. For purposes of these messages, an LI (Link) and a UL (Unlink) code have been added to HL7 Table 0119 - Order Control Codes.