22.12.2 Medical Records/Information Management (Document Management) (99.1.8)

23 .Medical Records/Information Management (Document Management) (9)

9

Gay Dolin Intelligent Medical Objects

Chapter Co-Chair

Chapter Co-Chair

Andrew StatlerCerner Corporation

23.1 Chapter 9 contents (9.1)

23.2 PURPOSE (9.2)

This chapter currently supports document management. In the future, it is intended also to support the data exchange needs of applications supporting other medical record functions, including chart location and tracking, deficiency analysis, consents, and release of information. The main purpose of the medical record is to produce an accurate, legal, and legible document that serves as a comprehensive account of healthcare services provided to a patient.

Document/reports supported in this chapter will meet the criteria as described in Chapter 7, "Observations" (section 7.2 - Purpose). The appropriate use of MDM messages versus ORU message has been clarified in 7.2.

23.2.1 Definition of Document Management Terms and Concepts (9.2.1)

This section provides definitions of terms used throughout this chapter. The intent of this part is to provide clarification on use and interpretation.

23.2.1.1 Addendum: (9.2.1.0)

An appendage to an existing document that contains supplemental information. The parent document remains in place and its content is unaltered.

23.2.1.2 Archived: (9.2.1.1)

A storage status in which a document has been stored off-line for long-term access.

23.2.1.3 Canceled: (9.2.1.2)

An availability status in which a document has been "removed" from a patient's record with no replacement. This is done when a document has been erroneously created or assigned to the incorrect patient.

23.2.1.4 Composite document: (9.2.1.3)

A document which consists of an original document and one or more addenda.

23.2.1.5 Document completion table: (9.2.1.4)

The following terms are used to describe the workflow progression of a document:

23.2.1.5.1 Authenticated: (9.2.1.4.1)

A completion status in which a document or entry has been signed manually or electronically by one or more individuals who attest to its accuracy. No explicit determination is made that the assigned individual has performed the authentication. While the standard allows multiple instances of authentication, it would be typical to have a single instance of authentication, usually by the assigned individual.

23.2.1.5.2 Dictated: (9.2.1.4.2)

A completion status in which information has been orally recorded but not yet transcribed.

23.2.1.5.3 Documented: (9.2.1.4.3)

A completion status in which document content, other than dictation, has been received but has not been translated into the final electronic format. Examples include paper documents, whether hand-written or typewritten, and intermediate electronic forms, such as voice to text.

23.2.1.5.4 In Progress/Assigned: (9.2.1.4.4)

A workflow status in which the recipient has assigned the material to personnel to perform the task of transcription. The document remains in this state until the document is transcribed.

23.2.1.5.5 Incomplete: (9.2.1.4.5)

A completion status in which information is known to be missing from a document.

23.2.1.5.6 Legally Authenticated: (9.2.1.4.6)

A completion status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry. This is the most mature state in the workflow progression.

23.2.1.5.7 Pre-Authenticated: (9.2.1.4.7)

A completion status in which a document is transcribed but not authenticated.

23.2.1.6 Edited Document: (9.2.1.5)

A document that alters an existing document which had not been made available for patient care (see also Section 9.2.1.9, "Replacement Document:").

23.2.1.7 New or Original Document: (9.2.1.6)

The first version of a document. The original may or may not be final or authenticated. An original document should have a set of associated statuses to define its current condition.

23.2.1.8 Obsolete: (9.2.1.7)

An availability status in which a document has been replaced by a document which contains revised content.

23.2.1.9 Purged: (9.2.1.8)

A storage status in which a document is no longer available in this system.

23.2.1.10 Replacement Document: (9.2.1.9)

A document that replaces an existing document. The original document becomes obsolete, but is still retained in the system for historical reference.

23.2.1.11 Restricted: (9.2.1.10)

A confidentiality status in which access to a document has institutionally assigned limitations.

23.2.1.12 Revised document: (9.2.1.11)

This is not a supported trigger event. See Sections 9.2.1.5, "Edited Document:", and 9.2.1.9 "Replacement Document:".

23.2.1.13 Transcription: (9.2.1.12)

A process of transforming dictated or otherwise documented information into an electronic format.

23.2.2 Definition of Consent Terms and Concepts (9.2.2)

23.2.2.1 Background Text: (9.2.2.0)

In most cases in the health field, consent must be "informed" consent. This means that the consenting individual must understand and appreciate the implications of what he or she is consenting to. Most consent processes involve providing background material describing the reasons for the proposed service, expected benefits and potential risks. It is important to have a record of what information was presented to the subject at the time of consent.

23.2.2.2 Consent Bypass Reason: (9.2.2.1)

There may arise situations in which an action must be performed without patient consent (i.e., retrieving an unconscious patient's drug history, performing life saving surgery, etc.). This field indicates the rationale for accessing information without obtaining the required consent.

23.2.2.3 Consent Decision Date/Time: (9.2.2.2)

Related to the above, there also needs to be a record of the time the subject actually made their consent decision.

23.2.2.4 Consent Disclosure Level: (9.2.2.3)

Identifies whether the subject was provided with information on the full background information on the procedure the subject is giving consent to; i.e., has all information needed for 'informed' consent been provided.

23.2.2.5 Consent Discussion Date/Time: (9.2.2.4)

For informed consent, a knowledgeable person must discuss the ramifications of consent with the subject. In some instances, this discussion is required to take place prior to the provision of consent. This ensures that the subject has sufficient time to consider the ramifications of his or her decision. To ensure that guidelines are followed, it is imperative to record when the consent information was initially discussed with the subject.

23.2.2.6 Consent Effective Date/Time: (9.2.2.5)

Not all consents take effect at the time the consent decision is made. They may not become effective for some time, or in certain circumstances they may even be retroactive. Use this field to record the effective time.

23.2.2.7 Consent End Date/Time: (9.2.2.6)

For most programs requiring voluntary participation, the decision to participate is not final and therefore may be revoked in the future. Therefore, when a patient makes the decision to revoke his or her consent, the date and time on which the decision was made must be recorded in order to provide a complete history of the consent. Alternatively, the initial consent may only have been granted for a limited period of time (i.e., 24 hours, 1 week, 1 year). If Consent End Date/Time is null, this should be interpreted as 'indefinite.'

23.2.2.8 Consent Form ID: (9.2.2.7)

Some institutions may have a set of pre-defined consent forms. Identifying the specific form identifies the details the subject is consenting to, as well as what information is on the form.

23.2.2.9 Consent Mode: (9.2.2.8)

The manner in which consent can be given may vary greatly within a specific program, from program to program, or from organization to organization. Therefore, the standard must allow applications to identify how consent was obtained (i.e., verbally, written, etc.).

23.2.2.10 Consent Non-disclosure Reason: (9.2.2.9)

Identifies why information was withheld from the patient (i.e., telling the patient may cause a worse outcome than performing the procedure).

23.2.2.11 Consent Segment (9.2.2.10)

The issue of patient consent has become more important, particularly in the tracking of consent for the release of or exchange of information. The pieces of information recorded when dealing with a patient consent tend to be similar, regardless of the purpose of the consent. This segment combines these pieces of information so that they can be used for consents of any type.

23.2.2.12 Consent Status: (9.2.2.11)

Consent can be pending (subject hasn't been asked yet), given, refused, revoked or even completely bypassed. Consent Status identifies what the status of a subject's consent is (or was at a given point in time).

23.2.2.13 Consent Text: (9.2.2.12)

When recording consents electronically it is important to know the specific text that was presented to the consenting person.

23.2.2.14 Consent Type: (9.2.2.13)

In concert with giving consent, some programs may allow patients to request varying degrees of participation in a given program. I.e., if a consent program relates to a patient's entire medical record being available online they might have the opportunity to only reveal certain portions of that history, such as the drug history only.

23.2.2.15 Informational Material Supplied Indicator: (9.2.2.14)

As part of the informed consent process, additional material in the form of pamphlets, books, brochures, videos, etc., may be provided to the patient. An indication of whether this has been done is required. (Details on the materials provided will be sent using a separate segment.)

23.2.2.16 Subject Competence Indicator: (9.2.2.15)

One of the issues involved in informed consent is whether the subject is judged to be competent to provide consent on his or her own behalf. Factors involve age, mental capacity, and current state of health/awareness. A professional judgment about whether the subject is deemed competent must be made and recorded.

23.2.2.17 Subject-imposed Limitations: (9.2.2.16)

At the time of consent, the subject may wish to make modifications or add limitations to his or her consent. These modifications and limitations must be recorded.

23.2.2.18 Subject-specific Background Text: (9.2.2.17)

The reasons, expected benefits and risks may vary from subject to subject. It may be necessary to inform the subject of background information that only applies to his or her particular circumstance.

23.2.2.19 Subject-specific Consent Text: (9.2.2.18)

Sometimes consent forms have areas where details of the procedure or information distribution that are specific to a given consent instance are recorded, i.e., a variation on a common procedure, or an explicit listing of documents to be released. As this is part of the consent document, it needs to be recorded. It is helpful to keep this information separate from the standard 'template' consent text, as in most circumstances people viewing the consent will want to know "What's different from usual?"

23.2.2.20 Translation Type: (9.2.2.19)

To obtain informed consent, the patient must understand what he or she is consenting to. For subjects who do not understand the commonly used language of the institution, or who are unable to hear/read/speak, translation services may be required. An indication of what type(s) of translation were/will be performed is required.

23.2.2.21 Translator Assistance Indicator: (9.2.2.20)

To obtain informed consent, the patient must understand what he or she is consenting to. For subjects who do not understand the commonly used language of the institution, or who are unable to hear/read/speak, translation services may be required.

23.3 DOCUMENT MANAGEMENT SECTION (9.3)

This section defines the Medical Document Management (MDM) transaction set. It supports transmission of new or updated documents or information about their status(es). The trigger events and messages may be divided into two broad categories. One which describes the status of a document only and the other that describes the status and contains the document content itself.

The document management section is concerned primarily with the management of those documents and entries which are created as a result of a transcription process. Documents may be represented as a CDA document. See ANSI/HL7 CDA R2.0-2005 Section 3 for the correct method of transmitting CDA documents within an MDM message. These documents are created in two distinct contexts, one of which is related to an order and describes the procedures or activities associated with that order, and another which occurs independently of the order process. In this version we have added the ORC, OBR and associated NTE segments in order to provide full ordering context when appropriate for document management messages. The scope of this section also includes any document that contains data derived from orders or results but which must be treated as aggregate display data due to system limitations. This is a transition strategy to support integration of data across the continuum of care.

The content of a document can be represented with one or more observation segments (OBX). Where headings or separations naturally exist within the text, it is preferred that each of these blocks be represented as a separate OBX record. Where systems are able to decompose the text into separate medical concepts, the most atomic level of granularity of content should be represented, ideally with each medical concept being represented in its own OBX segment. Many of these concepts can be represented as coded entities.

23.4 Consent information (9.4)

23.4.1 Example 1 (9.4.1)

A patient decides to participate in a voluntary electronic drug history program. The patient records this decision in writing (Consent Mode) on a pre-designed consent form (Consent Form ID and Version) after the patient's health care service provider has explained the benefits and drawbacks of their participation (Consent Discussion Date/Time). In providing consent, the patient can also decide on the degree to which he or she will participate in the program (Consent Type). The consent decision (Consent Status) is recorded under the patient's name (use ROL segment) and the number of the paper-based form that the patient signed is recorded in the electronic consent gathering function (Consent Number). The patient's consent is effective from the day of the decision (Consent Effect Date/Time), but this consent can be terminated at the patient's discretion at a given date in the future (Consent End Date/Time). Several months later the patient is rushed into an emergency health care facility with what appears to be a drug reaction. While checking the patient's drug history, health care service providers find that the patient's drug history has controlled access. The patient is unable to provide access to this information given that patient's physical state, so the health care service provider circumvents the consent process (Non-consent Access Reason) in the interests of the patient's immediate well-being.

Example 2: A patient is seeking a therapeutic abortion. Because she is under 18, the practitioner must evaluate her competence to provide consent. The patient is deemed to be competent (Patient Competence Indicator). Local legislation mandates that the patient be counseled at least 24 hours prior to receiving the procedure. The patient is counseled, and the time recorded (Consent Discussion Date/Time). She is also given a pamphlet to take home and read (Informational Material Supplied Indicator). She returns the following day and signs the consent form (Consent Decision Date/Time).

Example 3: A deaf patient is admitted for labor and delivery. It becomes apparent the patient will require a cesarean section. A translator is required (Translator Assistance Indicator) who can translate sign language (Translation Type). The translator explains the details of the procedure the patient is being asked to consent to (Consent Text), the intention to use epidural anesthetic (Subject-specific Consent Text), the general risks associated with doing the procedure, as well as those with not doing the procedure (Background Text) and benefits associated with the epidural (Subject-specific Background Text). The patient agrees to the procedure, subject to the condition that she not be given any blood products for religious reasons (Subject-imposed Limitations).

Example 4: An employee signs a consent form authorizing (Consent Status) a hospital to request the employee's driving records from the local Department of Motor Vehicles (Consent Type).

Example 5: A patient signs a consent form to have basic diagnostic and billing information sent to that patient's insurer. The consent indicates that information may only be given to parties that are bound by HIPPA guidelines (Trust Agreement Restriction Type).

23.5 ASSUMPTIONS (9.5)

Within this section we have created a single message whose contents vary predicated on the trigger event. The following assumptions are made when the Medical Document Management (MDM) message is used:

• The application system is responsible for meeting all legal requirements (on the local, state, and federal levels) in the areas of document authentication, confidentiality, and retention.

• All documents are unique, and document numbers and file names are not reused.

• Documents may be associated with one or more orders.

23.6 TRIGGER EVENTS AND MESSAGE DEFINITIONS (9.6)

Each triggering event is listed below, along with the applicable form of the message exchange. The notation used to describe the sequence, optionality, and repetition of segments is described in Chapter 2, "Format for Defining Abstract Messages." There are two classes of events, those which contain notifications only, and those which contain both notifications and content (text contained in OBX segments).

When -MSH-9 is valued, the value of EVN-1 must be the same.

These triggering events are mainly associated with documents or entries that will be or have been transcribed. The types and appearance of the transcribed documents can vary greatly within a healthcare organization and between organizations. However, the main purpose of the transcription process is to document patient care or diagnostic results in a legible manner; these documents then become part of the legal medical record. The conceptual purpose of document notification is to facilitate updating the receiving system(s) with information from the source system(s), typically dictation or transcription systems, to indicate that an electronic document has been created or altered. The document notification message can be attached to an entire document (i.e., transcribed document) or can be transmitted stand-alone. In either case, the document notification is transmitted in the form of an unsolicited update or in response to a record-oriented query. A document notification message can be created under a variety of circumstances such as when: 1) dictation has been completed; 2) a document has been transcribed; or, 3) the status of a document has been changed, i.e., when a document has been authenticated.

Also, the orders represented by the ORC/OBR segments must be wholly and exclusively satisfied by the TXA/OBX content. "Wholly satisfied" means there are no other orders related to the TXA/OBX content other than those specified by the ORC/OBR segments. "Exclusively satisfied" means that the actions described by the ORC/OBR segments do not contain actions not addressed by the TXA/OBX content. Thus, the TXA/OBX context must satisfy all instances of ORC/OBR as indicated by ORC-7 Quantity/Timing, OBR-27 Quantity/Timing or the TQ1/ TQ2 segments.

• The placer order number may exist in the ORC, OBR and TXA. If valued in the ORC or OBR and the TXA is present, it should not be valued. If TXA is valued it should be ignored.

• The filler order number may exist in the ORC, OBR and TXA. If valued in the ORC or OBR and the TXA is present, it should not be valued. If TXA is valued it should be ignored.

• Generally the OBR-32 Principal interpreter and the TXA -22.1 Authentication person are conceptually the same. Normally only the TXA-22.1 should be valued. If both are valued, the TXA-22.1 takes precedence.

• The OBR-35 Transcriptionist and the TXA -11 Transcriptionist are conceptually the same. Normally only the TXA-11 should be valued. If both are valued, the TXA-11 takes precedence.

23.6.1 MDM/ACK - Original Document Notification (Event T01) (9.6.1)

This is a notification of the creation of a document without the accompanying content. There are multiple approaches by which systems become aware of documents:

Scenario A: A document is dictated and chart tracking system is notified that it has been dictated and is awaiting transcription.

Scenario B: Dictation is transcribed and chart tracking system is notified that the document exists and requires authentication.

Scenario C: A provider orders a series of three X-rays. The radiologist dictates a single document which covers all three orders. Multiple placer numbers are used to identify each of these orders.

• Message
• ACK Choreography
• FHIR Structure Definition
• v2.xml XSD
• ER7 Example
• XML Example

Segment	Cardinality	Implement	Status
MDM^T01^MDM_T01
MSH Message Header	[1..1]	SHALL
ARV Access Restriction			v2.9
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
EVN Event Type	[1..1]	SHALL	B, v2.5
PID Patient Identification	[1..1]	SHALL
PRT Participation Information
PV1 Patient Visit	[1..1]	SHALL
PRT Participation Information
COMMON_ORDER
ORC Common Order	[1..1]	SHALL
PRT Participation Information
TIMING
TQ1 Timing/Quantity	[1..1]	SHALL
TQ2 Timing/Quantity Relationship
OBR Observation Request	[1..1]	SHALL
PRT Participation Information
NTE Notes and Comments
TXA Transcription Document Header	[1..1]	SHALL
CON Consent Segment

 

MDM_T01

MSH-15	MSH-16	Immediate ACK	Application Ack
Blank	Blank	ACK^T11^ACK	-
Blank	Blank	ACK^T09^ACK	-
Blank	Blank	ACK^T01^ACK	-
NE	NE	-	-
NE	NE	-	-
NE	NE	-	-
AL, SU, ER	NE	ACK^T11^ACK	-
AL, SU, ER	NE	ACK^T09^ACK	-
AL, SU, ER	NE	ACK^T01^ACK	-
NE	AL, SU, ER	-	ACK^T11^ACK
NE	AL, SU, ER	-	ACK^T09^ACK
NE	AL, SU, ER	-	ACK^T01^ACK
AL, SU, ER	AL, SU, ER	ACK^T11^ACK	ACK^T11^ACK
AL, SU, ER	AL, SU, ER	ACK^T09^ACK	ACK^T09^ACK
AL, SU, ER	AL, SU, ER	ACK^T01^ACK	ACK^T01^ACK

We need some ER7 examples...

We need some XML examples...

• Message
• ACK Choreography
• FHIR Structure Definition
• v2.xml XSD
• ER7 Example
• XML Example

Segment	Cardinality	Implement	Status
ACK^T01^ACK
MSH Message Header	[1..1]	SHALL
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
MSA Message Acknowledgment	[1..1]	SHALL
ERR Error

 

ACK

We need some ER7 examples...

We need some XML examples...

23.6.2 MDM/ACK - Original Document Notification and Content (Event T02) (9.6.2)

This is a notification of the creation of a document with the accompanying content.

Scenario A: Dictation is transcribed and the chart tracking system is notified that the document exists and requires authentication. The content of the document is transmitted along with the notification.

Scenario B: A provider orders a series of three X-rays. The radiologist's dictation is transcribed in a single document, which covers all three orders. Multiple placer numbers are used to identify each of the orders within the single document message. The notification and document content are transmitted.

• Message
• ACK Choreography
• FHIR Structure Definition
• v2.xml XSD
• ER7 Example
• XML Example

Segment	Cardinality	Implement	Status
MDM^T02^MDM_T02
MSH Message Header	[1..1]	SHALL
ARV Access Restriction			v2.9
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
EVN Event Type	[1..1]	SHALL	B, v2.5
PID Patient Identification	[1..1]	SHALL
PRT Participation Information
PV1 Patient Visit	[1..1]	SHALL
PRT Participation Information
COMMON_ORDER
ORC Common Order	[1..1]	SHALL
PRT Participation Information
TIMING
TQ1 Timing/Quantity	[1..1]	SHALL
TQ2 Timing/Quantity Relationship
OBR Observation Request	[1..1]	SHALL
PRT Participation Information
NTE Notes and Comments
TXA Transcription Document Header	[1..1]	SHALL
CON Consent Segment
OBSERVATION	[1..*]	SHALL
OBX Observation/Result	[1..1]	SHALL
PRT Participation Information
NTE Notes and Comments

 

MDM_T02

MSH-15	MSH-16	Immediate ACK	Application Ack
Blank	Blank	ACK^T08^ACK	-
Blank	Blank	ACK^T10^ACK	-
Blank	Blank	ACK^T04^ACK	-
Blank	Blank	ACK^T02^ACK	-
NE	NE	-	-
NE	NE	-	-
NE	NE	-	-
NE	NE	-	-
AL, SU, ER	NE	ACK^T10^ACK	-
AL, SU, ER	NE	ACK^T02^ACK	-
AL, SU, ER	NE	ACK^T08^ACK	-
AL, SU, ER	NE	ACK^T04^ACK	-
NE	AL, SU, ER	-	ACK^T02^ACK
NE	AL, SU, ER	-	ACK^T04^ACK
NE	AL, SU, ER	-	ACK^T08^ACK
NE	AL, SU, ER	-	ACK^T10^ACK
AL, SU, ER	AL, SU, ER	ACK^T10^ACK	ACK^T10^ACK
AL, SU, ER	AL, SU, ER	ACK^T02^ACK	ACK^T02^ACK
AL, SU, ER	AL, SU, ER	ACK^T08^ACK	ACK^T08^ACK
AL, SU, ER	AL, SU, ER	ACK^T04^ACK	ACK^T04^ACK

We need some ER7 examples...

We need some XML examples...

• Message
• ACK Choreography
• FHIR Structure Definition
• v2.xml XSD
• ER7 Example
• XML Example

Segment	Cardinality	Implement	Status
ACK^T02^ACK
MSH Message Header	[1..1]	SHALL
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
MSA Message Acknowledgment	[1..1]	SHALL
ERR Error

 

ACK

We need some ER7 examples...

We need some XML examples...

23.6.3 MDM/ACK - Document Status Change Notification (Event T03) (9.6.3)

This is a notification of a change in a status of a document without the accompanying content.

Scenario: A document is authenticated. Notification is sent to the chart tracking system and is used to update the document status from pre-authenticated to authenticated or legally authenticated.

A change in any of the following independent status characteristics would cause a message to be sent:

• Completion Status

• Confidentiality Status

• Availability Status (the Availability Status of "cancelled" is supported in T11 (document cancel notification) or T03)

• Storage Status

• Message
• ACK Choreography
• FHIR Structure Definition
• v2.xml XSD
• ER7 Example
• XML Example

Segment	Cardinality	Implement	Status
MDM^T03^MDM_T01
MSH Message Header	[1..1]	SHALL
ARV Access Restriction			v2.9
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
EVN Event Type	[1..1]	SHALL	B, v2.5
PID Patient Identification	[1..1]	SHALL
PRT Participation Information
PV1 Patient Visit	[1..1]	SHALL
PRT Participation Information
COMMON_ORDER
ORC Common Order	[1..1]	SHALL
PRT Participation Information
TIMING
TQ1 Timing/Quantity	[1..1]	SHALL
TQ2 Timing/Quantity Relationship
OBR Observation Request	[1..1]	SHALL
PRT Participation Information
NTE Notes and Comments
TXA Transcription Document Header	[1..1]	SHALL
CON Consent Segment

 

MDM_T01

MSH-15	MSH-16	Immediate ACK	Application Ack
Blank	Blank	ACK^T11^ACK	-
Blank	Blank	ACK^T09^ACK	-
Blank	Blank	ACK^T01^ACK	-
NE	NE	-	-
NE	NE	-	-
NE	NE	-	-
AL, SU, ER	NE	ACK^T11^ACK	-
AL, SU, ER	NE	ACK^T09^ACK	-
AL, SU, ER	NE	ACK^T01^ACK	-
NE	AL, SU, ER	-	ACK^T11^ACK
NE	AL, SU, ER	-	ACK^T09^ACK
NE	AL, SU, ER	-	ACK^T01^ACK
AL, SU, ER	AL, SU, ER	ACK^T11^ACK	ACK^T11^ACK
AL, SU, ER	AL, SU, ER	ACK^T09^ACK	ACK^T09^ACK
AL, SU, ER	AL, SU, ER	ACK^T01^ACK	ACK^T01^ACK

We need some ER7 examples...

We need some XML examples...

Segment	Cardinality	Implement	Status
ACK^T03^ACK
MSH Message Header	[1..1]	SHALL
SFT Software Segment
UAC User Authentication Credential Segment	[0..1]
MSA Message Acknowledgment	[1..1]	SHALL
ERR Error