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Advisory: Order Status Values are Inappropriately Mapped in Some Circumstances

This problem affects the following products:

  • HealthShare Unified Care Record, all versions
  • HealthShare Health Connect, all versions
  • InterSystems IRIS for Health, all versions

In InterSystems SDA data model, orders are captured in the following streamlet types:

  • Medication
  • Vaccination
  • LabOrder
  • RadOrder
  • OtherOrder

Each of these orders may contain a Status property.

  • Inbound data transformations map values from source data into the SDA Status property for each type of order.
  • Outbound data transformations map the SDA Status property to target data standards.
  • Clinical Viewer and Personal Community apply additional transformations to the SDA Status property when displaying the data for use in those systems.

InterSystems has identified the following issue with these transformations:
Inappropriate or missing mappings may result in inaccurate or ambiguous information regarding the status of the order.

This has been identified as a clinical safety risk as this information may be used in clinical decision making. The details regarding the impacted transformations are detailed in this advisory.

  • All HealthShare solution customers are affected by this issue.
  • Health Connect and InterSystems IRIS for Health customers are affected by this issue if they store Medication, Vaccination, LabOrder, RadOrder, or OtherOrder data in SDA.

A fix is not yet available for this issue. InterSystems recommends that customers notify their users and recipients of outbound data that order status information should not be relied upon for clinical decision making.

Additional Information

The values from each source format are mapped to values within SDA and then may be further transformed upon ingestion into downstream systems or for outbound data standards. For example, a value of “HD” from HL7v2 is stored as “H” in SDA and displays as “On Hold” in Clinical Viewer and Personal Community. This is an example of an appropriate mapping where the meaning of the source value is retained.

There are a very large number of mappings between source and target values across all of InterSystem's data transformations. Each mapping was reviewed by the InterSystem's clinical safety team using a standardized process to determine which values were appropriately and inappropriately mapped.

In each of the following tables only the inappropriate mappings are listed. If a source value or target format/system and value is not listed here, the mapping has been assessed to be appropriate. For example:

  • The HL7v2 value of “ER” is appropriately retained in SDA as “ER” and appropriately displayed in Personal Community as “ER”
  • The value is inappropriately displayed in Clinical Viewer as “Verified” and inappropriately mapped in outbound CDA/C-CDA and FHIR data

The following tables will list only the “ER” mappings for Clinical Viewer, CDA/C-CDA, and FHIR, but not for SDA and Personal Community.

Medication Status

Source Properties Populating the Medication Status Property:

Source Format

Source Property

HL7v2

ORC-5 (Order Status Field)

CDA C32, C-CDA 1.1, and C-CDA 2.1

·  If supply moodCode (/entry/substanceAdministration/entryRelationship/supply/@moodCode) ='EVN' then Status='E'

·  If CDA status entryRelationship code (entryRelationship[@typeCode='REFR']/observation[code/@code='33999-4']/value/@code) ='421139008' then SDA Status='H'.

·  If CDA status entryRelationship code (entryRelationship[@typeCode='REFR']/observation[code/@code='33999-4']/value/@code) ='55561003' then SDA Status='IP'.

·  Otherwise SDA Status='I'.

FHIR STU3 MedicationDispense

status

FHIR STU3 MedicationRequest

status

FHIR R4 MedicationStatement

status

Inappropriate Mappings of Source to Target Values for Medications:

Source Format

Source Value

Target Format/System

Target Value

HL7v2

ER

Clinical Viewer

Verified

HL7v2

ER 

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

HL7v2

ER

FHIR STU3 MedicationDispense, MedicationRequest

·  stopped

HL7v2

ER

FHIR R4 MedicationDispense, MedicationStatement, MedicationRequest

stopped

HL7v2 

(null)

SDA

V

HL7v2

(null)

Clinical Viewer

Verified

HL7v2 

(null)

Personal Community

Verified

HL7v2 

(null)

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

HL7v2 

(null)

FHIR STU3 MedicationDispense, MedicationRequest

completed

HL7v2

(null)

FHIR R4 MedicationDispense, MedicationStatement, MedicationRequest

completed

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

Clinical Viewer

Verified

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

CDA C32, C-CDA 1.1, C-CDA 2.1.

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

SDA

I

CDA C32, C-CDA 1.1, C-CDA 2.1 

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

Clinical Viewer

Inactive

CDA C32, C-CDA 1.1, C-CDA 2.1 

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

Personal Community

Inactive

CDA C32, C-CDA 1.1, C-CDA 2.1

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "No"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

CDA C32, C-CDA 1.1, C-CDA 2.1

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

FHIR STU3 MedicationDispense, MedicationRequest

entered-in-error

CDA C32, C-CDA 1.1, C-CDA 2.1

Medication status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

FHIR R4 MedicationDispense, MedicationStatement, MedicationRequest

entered-in-error

FHIR STU3 MedicationRequest

unknown or draft

Clinical Viewer

Verified

FHIR STU3 MedicationRequest

unknown or draft

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

FHIR STU3 MedicationRequest

unknown or draft

FHIR STU3 MedicationRequest, MedicationDispense

null

FHIR R4 MedicationStatement

unknown

Clinical Viewer

Verified

FHIR R4 MedicationStatement

unknown

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

FHIR R4 MedicationStatement

unknown

FHIR STU3 MedicationRequest, MedicationDispense

null

FHIR R4 MedicationStatement

intended or not-taken

Clinical Viewer

Verified

FHIR R4 MedicationStatement

intended or not-taken

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Current Med?" column as "Yes"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 73425007 (Inactive)

FHIR R4 MedicationStatement

intended or not-taken

FHIR STU3 MedicationRequest, MedicationDispense

null

FHIR R4 MedicationStatement

intended or not-taken

FHIR R4 MedicationDispense, MedicationStatement, MedicationRequest

unknown

Vaccination Status

Source Properties Populating the Vaccination Status Property:

Source Format

Source Property

HL7v2

ORC-5 (Order Status Field)

CDA C32, C-CDA 1.1, and C-CDA 2.1

·  If supply moodCode (/entry/substanceAdministration/entryRelationship/supply/@moodCode) ='EVN' then Status='E'

·  If CDA status entryRelationship code (entryRelationship[@typeCode='REFR']/observation[code/@code='33999-4']/value/@code) ='421139008' then SDA Status='H'.

·  If CDA status entryRelationship code (entryRelationship[@typeCode='REFR']/observation[code/@code='33999-4']/value/@code) ='55561003' then SDA Status='IP'.

·  Otherwise SDA Status='I'.

FHIR STU3 Immunization

status

FHIR R4 Immunization

status

Inappropriate Mappings of Source to Target Values for Vaccinations:

Source Format

Source Value

Target Format/System

Target Value

HL7v2

ER

Clinical Viewer

Verified

HL7v2

ER 

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Status" column as "Completed"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 55561003 (Active)

HL7v2

ER 

FHIR STU3 Immunization

Results in an invalid resource due to empty status property

HL7v2

ER 

FHIR R4 Immunization

Results in an invalid resource due to empty status property

HL7v2

null

SDA

V

HL7v2

null

Clinical Viewer

Verified

HL7v2

null

Personal Community

Verified

HL7v2

null

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Status" column as "Completed"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 55561003 (Active)

HL7v2

null

FHIR STU3 Immunization

Results in an invalid resource due to empty status property

HL7v2

null

FHIR R4 Immunization

Results in an invalid resource due to empty status property

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

Clinical Viewer

Verified

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

CDA C32, C-CDA 1.1, C-CDA 2.1

·  HTML table displays value in "Status" column as "Completed"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 55561003 (Active)

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

FHIR STU3 Immunization

Results in an invalid resource due to empty status property

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

FHIR R4 Immunization

Results in an invalid resource due to empty status property

CDA C32, C-CDA 1.1, C-CDA 2.1.

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

SDA

I

CDA C32, C-CDA 1.1, C-CDA 2.1 

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

Clinical Viewer

Inactive

CDA C32, C-CDA 1.1, C-CDA 2.1 

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

Personal Community

Inactive

CDA C32, C-CDA 1.1, C-CDA 2.1 

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

CDA C32, C-CDA 1.1, C-CDA 2.1 

·  HTML table displays value in "Status" column as "Completed"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 55561003 (Active)

CDA C32, C-CDA 1.1, C-CDA 2.1 

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

FHIR STU3 Immunization

entered-in-error

CDA C32, C-CDA 1.1, C-CDA 2.1 

Immunization status entryRelationship is absent or does not contain SNOMED codes 55561003 (Active) or 421139008 (On Hold)

FHIR R4 Immunization

entered-in-error

FHIR R4 Immunization

not-done

Clinical Viewer

Verified

FHIR R4 Immunization

not-done

CDA C32, C-CDA 1.1, C-CDA 2.1 

·  HTML table displays value in "Status" column as "Completed"

·  substanceAdministration statusCode = completed

·  status entryRelationship = 55561003 (Active)

FHIR R4 Immunization

not-done

FHIR STU3 Immunization

Results in an invalid resource due to empty status property

FHIR R4 Immunization

not-done

FHIR R4 Immunization

Results in an invalid resource due to empty status property

LabOrder, RadOrder, OtherOrder

Source Properties Populating the LabOrder, RadOrder, OtherOrder Status Property:

Source Format

Source Property

HL7v2

ORC-5 (Order Status Field)

FHIR STU3 DiagnosticReport

status

FHIR STU3 ProcedureRequest

status

FHIR R4 Diagnostic Report

status

FHIR R4 ServiceRequest

status

Inappropriate mappings of source to target values for LabOrder, RadOrder, and OtherOrder:

These streamlets may be associated with results. If results are present, the Status will be updated to “E” or “Executed”, regardless of the original value.

If results are not present, the source status values may be transformed. The inappropriate mappings are listed below.

Source Format

Source Value

Target Format/System

Target Value

HL7v2

ER

Clinical Viewer

Verified

HL7v2

ER 

FHIR STU3 ProcedureRequest

cancelled

HL7v2

ER 

FHIR R4 ServiceRequest

revoked

HL7v2

null

SDA

V

HL7v2

null

Clinical Viewer

Verified

HL7v2

null

Personal Community

Verified

HL7v2

null

FHIR STU3 ProcedureRequest

active

HL7v2

null

FHIR R4 ServiceRequest

active

HL7v2

Non-null value other than A, CA, DC, CM, ER, HD, I, IP, P, PO, Q, RP, S, U

Clinical Viewer

Verified

FHIR R4 DiagnosticReport

unknown

Clinical Viewer

Verified

FHIR R4 DiagnosticReport

entered-in-error

SDA

R

FHIR R4 DiagnosticReport

entered-in-error

Clinical Viewer

Replaced

FHIR R4 DiagnosticReport

entered-in-error

Personal Community

Replaced

FHIR R4 DiagnosticReport

amended, appended, corrected

SDA

K

FHIR R4 DiagnosticReport

amended, appended, corrected

Clinical Viewer

Verified

FHIR R4 DiagnosticReport

amended, appended, corrected

Personal Community

K

FHIR STU3 ProcedureRequest

unknown

Clinical Viewer

Verified

FHIR STU3 ProcedureRequest

completed

FHIR STU3 ProcedureRequest

unknown

FHIR STU3 ProcedureRequest

completed

FHIR R4 ServiceRequest

unknown

FHIR STU3 ProcedureRequest

draft

FHIR STU3 ProcedureRequest

active

FHIR STU3 ProcedureRequest

draft

FHIR R4 ServiceRequest

active

FHIR STU3 ProcedureRequest

entered-in-error

SDA

R

FHIR STU3 ProcedureRequest

entered-in-error

Clinical Viewer

Replaced

FHIR STU3 ProcedureRequest

entered-in-error

Personal Community

Replaced

FHIR R4 ServiceRequest

unknown

Clinical Viewer

Verified

FHIR R4 ServiceRequest

completed

FHIR STU3 ProcedureRequest

unknown

FHIR R4 ServiceRequest

completed

FHIR R4 ServiceRequest

unknown

FHIR R4 ServiceRequest

draft

FHIR STU3 ProcedureRequest

active

FHIR R4 ServiceRequest

draft

FHIR R4 ServiceRequest

active

FHIR R4 ServiceRequest

entered-in-error

SDA

R

FHIR R4 ServiceRequest

entered-in-error

Clinical Viewer

Replaced

FHIR R4 ServiceRequest

entered-in-error

Personal Community

Replaced

Reference Information

This issue is identified as HSIEC-6741. If you have any questions regarding this alert, please contact the Worldwide Response Center (WRC).