DD ENV 12539:1998

This standard DD ENV 12539:1998 Medical informatics. Request and report messages for diagnostic service departments is classified in these ICS categories:

• 35.240.80 IT applications in health care technology
• 11.040.55 Diagnostic equipment

1.1 This European Prestandard specifies general messages to enable electronic exchange of requests for, and reports of, diagnostic services. The information exchanges covered are those between computer systems used by diagnostic service departments and computer systems used by healthcare parties requesting, or receiving results of, diagnostic services.

1.2 Within limits identified by subsequent clauses of this scope statement, this European Prestandard is applicable to messages requesting, or reporting on the results, of the following diagnostic services:

• Radiology;

• Nuclear medicine;

• Ultrasound;

• Other imaging techniques (e.g. magnetic resonance tomography);

• Electrophysiology;

• Physiological function tests;

• Diagnostic audiology;

• Cytology;

• Anatomic pathology;

• Histopathology; and

• Post-mortem studies (autopsies).

The messages specified also allow the inclusion of clinical observations about the patient where these are required to perform or interpret the results of these studies.

1.3 This European Prestandard is not applicable to messages requesting or reporting on the results of diagnostic laboratory specialties already covered by ENV 1613:

• Clinical Chemistry;

• Clinical Biochemistry;

• Toxicology;

• Clinical Immunology;

• Immunohaematology;

• Haematology;

• Clinical Microbiology (including Bacteriology, Mycology, Parasitology and Virology).

1.4 This European Prestandard is not applicable to messages requesting or reporting on blood transfusion services.

1.5 This European Prestandard does not specify the manner in which diagnostic service department services are divided between specialties as this varies in accordance with different national and local practices.

1.6 The messages specified by this European Prestandard, supplement those specified in other related standards, such as ENV 1613. In some borderline situations more than one member of this family of standards may meet the requirements. In these circumstances, the decision as to which messages are applicable to particular departments or studies in particular healthcare environments should be agreed by communicating parties.

1.7 The scope of the messages specified by this European Prestandard, comprises requests and results related to investigations carried out by diagnostic service departments on patients. This European Prestandard is applicable whether the healthcare party communicating with the diagnostic service department is a person (such as a doctor or other healthcare professional) or an organisation (such as a hospital, clinic or department). A diagnostic service department may itself act as the healthcare party submitting requests to, or receiving results from other diagnostic service departments. However, this European Prestandard has not been developed to meet the needs of messages that are specific to communications between one diagnostic service department and another.

1.8 This European Prestandard is applicable to requests for diagnostic services to be performed on:

• patients;

• samples, obtained from a patient, submitted to the diagnostic service department by the requester;

• samples that are to be obtained, from a patient, by the diagnostic department in response to a request for an investigation;

• materials or information resulting from a previous diagnostic service (e.g. a second opinion on films from a previous diagnostic service procedure).

It is also applicable to modifications or cancellations of previously issued requests.

1.9 This European Prestandard is applicable to reports of the results of diagnostic services. The report message it specifies supports the communication of partial, supplementary, complete and cumulative reports.

It is also applicable to modifications and cancellations of previously issued reports.

1.10 This European Prestandard permits diagnostic service report messages to be sent whether or not a diagnostic service request message has been received.

1.11 This European Prestandard also specifies diagnostic service plan report messages. These may be sent before a diagnostic service has been undertaken to communicate information about the acceptance of a diagnostic service request and the planning and progress of the requested diagnostic services. These messages also allow the diagnostic service provider to send the service requester instruction for preparation of the patient prior to the investigation.

1.12 The messages specified in this European Prestandard do not support standing orders for diagnostic services.

1.13 The messages specified in this European Prestandard do not support the communication of graphical, image or dynamic signal information that forms part of a request for or result of a diagnostic service. However, provision is made within the messages for external references to files which may contain these types of information.

1.14 This European Prestandard has not been developed to meet the needs of messages supporting administration, financing, management, interpersonal mail or external quality control, nor of messages communicating sample collection lists, work lists or queries.

1.15 The provisions of this European Prestandard have been validated in the domains and for the purposes described above. However, messages conforming to this European Prestandard may be considered by some user communities to meet their needs for purposes outside this scope. Use of the messages in such circumstances is not precluded by the scope.

1.16 While the messages specified in this European Prestandard may convey clinical and administrative information concerning patients, the way in which this information is treated in this European Prestandard does not constrain the development of future standards for the electronic healthcare record or for other clinical and administrative messages.