MedMij:V2020.01/FHIR BGZ 2017: verschil tussen versies
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{{DISPLAYTITLE:MedMij FHIR Implementation Guide: BgZ {{VersieInfo|BgZ}}}} | {{DISPLAYTITLE:MedMij FHIR Implementation Guide: BgZ {{VersieInfo|BgZ}}}} | ||
| − | {{MedMij: | + | {{MedMij:V2020.01/Issuebox_FHIR_IG}} |
[[Bestand:MedMij2.png |link=https://www.medmij.nl/|rechts|Naar medmij.nl]] | [[Bestand:MedMij2.png |link=https://www.medmij.nl/|rechts|Naar medmij.nl]] | ||
| Regel 7: | Regel 7: | ||
<imagemap>Bestand:Leeswijzer-technisch-banner 03 white.png|center|400px|alt=Afspraken-Functioneel-Technisch | <imagemap>Bestand:Leeswijzer-technisch-banner 03 white.png|center|400px|alt=Afspraken-Functioneel-Technisch | ||
circle 241 216 211 [https://www.medmij.nl/afsprakenstelsel Afsprakenstelsel] | circle 241 216 211 [https://www.medmij.nl/afsprakenstelsel Afsprakenstelsel] | ||
| − | circle 1013 224 212 [[MedMij: | + | circle 1013 224 212 [[MedMij:V2020.01/OntwerpBGZ_2017|Functioneel]] |
| − | circle 1787 230 212 [[MedMij: | + | circle 1787 230 212 [[MedMij:V2020.01/FHIR_IG|Technisch]] |
desc none | desc none | ||
</imagemap> | </imagemap> | ||
| Regel 15: | Regel 15: | ||
==Introduction== | ==Introduction== | ||
| − | [[Bestand:Functioneel-02.png|link=MedMij: | + | [[Bestand:Functioneel-02.png|link=MedMij:V2020.01/Ontwerpen |100px|rechts|Functional design|Go to functional design]] |
The program ‘Registratie aan de bron’ (Clinical documentation at the point of care) has defined Health and Care Information models ([https://zibs.nl/wiki/HCIM_Mainpage HCIMs] (English) or [https://zibs.nl/wiki/ZIB_Hoofdpagina zibs] (Dutch)) for The Netherlands. Next to these HCIMs, the program ‘Registratie aan de bron’ also made a selection of these HCIMs into the so-called ‘Basisgegevensset Zorg’ (Common Clinical Dataset, a Dutch version of a ‘patient summary’, further referred to as ‘BgZ’). The BgZ serves as a minimal healthcare dataset that is always appropriate for caregivers in order to provide continuity of care for a patient and can be seen as a representation of a patient summary. | The program ‘Registratie aan de bron’ (Clinical documentation at the point of care) has defined Health and Care Information models ([https://zibs.nl/wiki/HCIM_Mainpage HCIMs] (English) or [https://zibs.nl/wiki/ZIB_Hoofdpagina zibs] (Dutch)) for The Netherlands. Next to these HCIMs, the program ‘Registratie aan de bron’ also made a selection of these HCIMs into the so-called ‘Basisgegevensset Zorg’ (Common Clinical Dataset, a Dutch version of a ‘patient summary’, further referred to as ‘BgZ’). The BgZ serves as a minimal healthcare dataset that is always appropriate for caregivers in order to provide continuity of care for a patient and can be seen as a representation of a patient summary. | ||
| − | A subselection of the published [https://zibs.nl/wiki/HCIM_Release_2017(EN) HCIMs release 2017] constitute the [https://www.registratieaandebron.nl/pdf/BgZ_specificatie_obv_zibs_2017_v1.1.pdf BgZ 2017]. The BgZ makes a subselection of the information concepts within the HCIMs or restricts the HCIMs to a certain category. For example, only include the general practitioner of the patient or only the last known value of 'X'. MedMij created FHIR profiles that represent these HCIMs completely if no existing and usable profiles were available. The profiles represent their entire respective HCIM, to make them applicable in a broader context than a patient summary or even the MedMij context. An overview of the profiles can be found at the [[MedMij: | + | A subselection of the published [https://zibs.nl/wiki/HCIM_Release_2017(EN) HCIMs release 2017] constitute the [https://www.registratieaandebron.nl/pdf/BgZ_specificatie_obv_zibs_2017_v1.1.pdf BgZ 2017]. The BgZ makes a subselection of the information concepts within the HCIMs or restricts the HCIMs to a certain category. For example, only include the general practitioner of the patient or only the last known value of 'X'. MedMij created FHIR profiles that represent these HCIMs completely if no existing and usable profiles were available. The profiles represent their entire respective HCIM, to make them applicable in a broader context than a patient summary or even the MedMij context. An overview of the profiles can be found at the [[MedMij:V2020.01/FHIR_BGZ_2017#List_of_profiles|list of profiles]]. |
| − | The patient journey of [https://www.nictiz.nl/ehealth/MedMij Thomas van Beek], provides a patients context for exchanging a patient summary from a healthcare provider's system (XIS) to a personal health record (PHR). MedMij created a [ | + | The patient journey of [https://www.nictiz.nl/ehealth/MedMij Thomas van Beek], provides a patients context for exchanging a patient summary from a healthcare provider's system (XIS) to a personal health record (PHR). MedMij created a [[MedMij:V2020.01/Ontwerpen|functional design]] of the BgZ use case. This use case consists of enabling a patient to view his own BgZ in a PHR. This page will elaborate further on the HL7 FHIR details needed to exchange the BgZ information using FHIR. |
| − | '''Note''': This implementation guide builds on the general guidelines described in the [[MedMij: | + | '''Note''': This implementation guide builds on the general guidelines described in the [[MedMij:V2020.01/FHIR_IG#Use case overarching principles|use case overarching principles]]. |
==Actors involved== | ==Actors involved== | ||
| Regel 64: | Regel 64: | ||
===PHR: request message=== | ===PHR: request message=== | ||
| − | The PHR system requests the BgZ using individual [https://www.hl7.org/fhir/stu3/search.html search] interactions. The BgZ consists of multiple FHIR resources with certain constraints. To obtain the patient's | + | The PHR system requests the BgZ using individual [https://www.hl7.org/fhir/stu3/search.html search] interactions. The BgZ consists of multiple FHIR resources with certain constraints. To obtain the patient's BgZ, the client can use multiple individual search operations based on specified search queries. The interactions are performed by an HTTP GET as shown: |
<code>GET [base]/[type]{?[parameters]}</code> | <code>GET [base]/[type]{?[parameters]}</code> | ||
| − | The table below shows in the first four columns the | + | The table below shows in the first four columns the BgZ sections, the HCIMs that constitute those sections and the specific content of the BgZ. The last column shows the FHIR search queries to obtain the BgZ information. These queries and expected responses are based on profiles listed in [[#List_of_profiles| this section]]. |
{| class="wikitable collapsible" width="100%" style="horizontal-align: right" | {| class="wikitable collapsible" width="100%" style="horizontal-align: right" | ||
| Regel 75: | Regel 75: | ||
!style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | HCIM EN | !style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | HCIM EN | ||
!style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | Content | !style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | Content | ||
| − | !style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | Search URL<ref>See [[MedMij: | + | !style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:10px" | Search URL<ref>See [[MedMij:V2020.01/FHIR_IG#Search_URLs_and_search_parameters|Search URLs and search parameters]] for the interpretation of these search URLs</ref> |
|- | |- | ||
| 1 | | 1 | ||
| Regel 165: | Regel 165: | ||
| Known administration agreements | | Known administration agreements | ||
| <pre>GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&_include=MedicationDispense:medication</pre> | | <pre>GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&_include=MedicationDispense:medication</pre> | ||
| + | <span id="AdministrationAgreementRemark"></span>{{NoteBox|The search on {{fhir|MedicationDispense.category}} requires a {{Simplifier|http://nictiz.nl/fhir/SearchParameter/Medications-category|nictiz.fhir.nl.stu3.zib2017|title= custom SearchParameter}} not represented in the FHIR specification. }} | ||
|- | |- | ||
| 11 | | 11 | ||
| Regel 223: | Regel 224: | ||
<pre>GET [base]/ProcedureRequest?status=active</pre> | <pre>GET [base]/ProcedureRequest?status=active</pre> | ||
<pre>GET [base]/ImmunizationRecommendation</pre> | <pre>GET [base]/ImmunizationRecommendation</pre> | ||
| − | <pre style="text-decoration: line-through;">GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&status=in-progress,preparation&_include=MedicationDispense:medication</pre> | + | {{NoteBox|The NL-CM:11.1.5 DesiredDateForRevaccination concept is incorrectly mapped onto the {{fhir|.recommendation.date}} element in the HCIM ImmunizationRecommendation profile. The proper element is actually {{fhir|.recommendation.dateCriterion}}. This will be fixed in the next breaking release. See [https://bits.nictiz.nl/browse/MM-2281 MM-2281] for more information.}}<pre style="text-decoration: line-through;">GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&status=in-progress,preparation&_include=MedicationDispense:medication</pre> |
<span id="MM115Remark"></span>{{NoteBox|PlannedCareActivityForTransfer for MedicationAdministration was found unimplementable as-is. Presumed solution will come from a future HCIM release. See [https://bits.nictiz.nl/browse/MM-115 MM-115] for more information.}} | <span id="MM115Remark"></span>{{NoteBox|PlannedCareActivityForTransfer for MedicationAdministration was found unimplementable as-is. Presumed solution will come from a future HCIM release. See [https://bits.nictiz.nl/browse/MM-115 MM-115] for more information.}} | ||
<pre>GET [base]/DeviceRequest?status=active&_include=DeviceRequest:device</pre> | <pre>GET [base]/DeviceRequest?status=active&_include=DeviceRequest:device</pre> | ||
| Regel 250: | Regel 251: | ||
The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of BgZ or a MedMij context. An example of reuse of existing profiles is those of the patient administration resources and vital signs. | The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of BgZ or a MedMij context. An example of reuse of existing profiles is those of the patient administration resources and vital signs. | ||
| − | {{MedMij: | + | {{MedMij:V2020.01/NoteBoxPackage|p1=nictiz.fhir.nl.stu3.bgz|p2=nictiz.fhir.nl.stu3.zib2017|v2Min=2.0.0|p3=nictiz.fhir.nl.stu3.eafspraak}} |
{| class="wikitable" style="horizontal-align: right" | {| class="wikitable" style="horizontal-align: right" | ||
| Regel 259: | Regel 260: | ||
!style="background-color: #1F497D; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:400px" | FHIR Profile | !style="background-color: #1F497D; color: white; font-weight: bold; text-align:left; background-color: #E3E3E3 width:400px" | FHIR Profile | ||
|- | |- | ||
| − | | 1 | + | | rowspan="2" | 1 |
| Patient | | Patient | ||
| − | |||
| Patient | | Patient | ||
| − | | {{Simplifier|http://fhir.nl/fhir/StructureDefinition/nl-core-patient|nictiz.fhir.nl.stu3.zib2017}} | + | | Patient |
| + | | rowspan="2" | {{Simplifier|http://fhir.nl/fhir/StructureDefinition/nl-core-patient|nictiz.fhir.nl.stu3.zib2017}} | ||
| + | |- | ||
| + | | BurgerlijkeStaat | ||
| + | | MaritalStatus | ||
| + | | Patient.maritalStatus | ||
|- | |- | ||
| − | | rowspan="3" |2 | + | | rowspan="3" | 2 |
| rowspan="3" | Betaler | | rowspan="3" | Betaler | ||
| rowspan="3" | Payer | | rowspan="3" | Payer | ||
| Regel 277: | Regel 282: | ||
| {{Simplifier|http://fhir.nl/fhir/StructureDefinition/nl-core-patient|nictiz.fhir.nl.stu3.zib2017}} | | {{Simplifier|http://fhir.nl/fhir/StructureDefinition/nl-core-patient|nictiz.fhir.nl.stu3.zib2017}} | ||
|- | |- | ||
| − | | rowspan="2" |3 | + | | rowspan="2" | 3 |
| BehandelAanwijzing | | BehandelAanwijzing | ||
| TreatmentDirective | | TreatmentDirective | ||
| Regel 295: | Regel 300: | ||
|- | |- | ||
| 5 | | 5 | ||
| − | | | + | | FunctioneleOfMentaleStatus |
| FunctionalOrMentalStatus | | FunctionalOrMentalStatus | ||
| Observation | | Observation | ||
| Regel 345: | Regel 350: | ||
|- | |- | ||
| rowspan="3" | 10 | | rowspan="3" | 10 | ||
| − | | | + | | MedicatieGebruik2 |
| − | | | + | | MedicationUse2 |
| MedicationStatement | | MedicationStatement | ||
| {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse|nictiz.fhir.nl.stu3.zib2017}} | | {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse|nictiz.fhir.nl.stu3.zib2017}} | ||
|- | |- | ||
| + | | Medicatieafspraak | ||
| MedicationAgreement | | MedicationAgreement | ||
| MedicationRequest | | MedicationRequest | ||
| {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement|nictiz.fhir.nl.stu3.zib2017}} | | {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement|nictiz.fhir.nl.stu3.zib2017}} | ||
|- | |- | ||
| + | | Toedieningsafspraak | ||
| AdministrationAgreement | | AdministrationAgreement | ||
| MedicationDispense | | MedicationDispense | ||
| Regel 447: | Regel 454: | ||
=Release notes= | =Release notes= | ||
| − | Release notes can be found on the [[MedMij: | + | Release notes can be found on the [[MedMij:V2020.01/OntwerpBGZ_2017#Release_notes|functional design page]]. |
Huidige versie van 22 nov 2022 om 13:35
1 Introduction
The program ‘Registratie aan de bron’ (Clinical documentation at the point of care) has defined Health and Care Information models (HCIMs (English) or zibs (Dutch)) for The Netherlands. Next to these HCIMs, the program ‘Registratie aan de bron’ also made a selection of these HCIMs into the so-called ‘Basisgegevensset Zorg’ (Common Clinical Dataset, a Dutch version of a ‘patient summary’, further referred to as ‘BgZ’). The BgZ serves as a minimal healthcare dataset that is always appropriate for caregivers in order to provide continuity of care for a patient and can be seen as a representation of a patient summary.
A subselection of the published HCIMs release 2017 constitute the BgZ 2017. The BgZ makes a subselection of the information concepts within the HCIMs or restricts the HCIMs to a certain category. For example, only include the general practitioner of the patient or only the last known value of 'X'. MedMij created FHIR profiles that represent these HCIMs completely if no existing and usable profiles were available. The profiles represent their entire respective HCIM, to make them applicable in a broader context than a patient summary or even the MedMij context. An overview of the profiles can be found at the list of profiles.
The patient journey of Thomas van Beek, provides a patients context for exchanging a patient summary from a healthcare provider's system (XIS) to a personal health record (PHR). MedMij created a functional design of the BgZ use case. This use case consists of enabling a patient to view his own BgZ in a PHR. This page will elaborate further on the HL7 FHIR details needed to exchange the BgZ information using FHIR.
Note: This implementation guide builds on the general guidelines described in the use case overarching principles.
2 Actors involved
| Actors | Systems | FHIR Capability Statements | |||
|---|---|---|---|---|---|
| Name | Description | Name | Description | Name | Description |
| Patient | The user of a personal healthcare environment. | PHR | Personal health record |  CapabilityStatement: Client
|
FHIR Client requirements |
| Healthcare professional | The user of a XIS | XIS | Healthcare information system | CapabilityStatement: Server
|
FHIR Server requirements |
3 Boundaries and Relationships
The BgZ 2017 v1.1 use case follows the BgZ v1.0 use case. The difference between the two is the underlying HCIMs, which have been upgraded from release 2015 to release 2017. The changes are documented in a release notes document.
The BgZ use case has similarities and differences with other use cases such as Medication Process, Vital Signs and Lab Results. These use cases use the same HCIM based FHIR profiles for exchanging information. The BgZ use case covers practically all profiles included in the other use cases. However, the BgZ differs in the scope of the actual health information content that should be exchanged. For example, the BgZ conveys only the last known lab result of each type while the Lab Results use case may cover all known information.
4 Use Case: Retrieve BGZ information
This FHIR implementation guide assumes that the PHR system is able to make a connection to the right XIS that contains the patient's information. It does not provide information on finding the right XIS nor does it provide information about security. Moreover, each transaction is performed in the context of a specific authenticated patient, for whose context (token) has been established using the authentication mechanisms described in the 'Afsprakenstelsel'. Each XIS Gateway is required to perform filtering based on the patient associated with the context for the request, so only the records associated with the authenticated patient are returned. For this reason, search parameters should not be included for patient identification.
4.1 PHR: request message
The PHR system requests the BgZ using individual search interactions. The BgZ consists of multiple FHIR resources with certain constraints. To obtain the patient's BgZ, the client can use multiple individual search operations based on specified search queries. The interactions are performed by an HTTP GET as shown:
GET [base]/[type]{?[parameters]}
The table below shows in the first four columns the BgZ sections, the HCIMs that constitute those sections and the specific content of the BgZ. The last column shows the FHIR search queries to obtain the BgZ information. These queries and expected responses are based on profiles listed in this section.
| # | BgZ Section | HCIM EN | Content | Search URL[1] | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Patient information | Patient | Identification, birth date, gender, deceased indicator, contact details, last known marital status, and general practitioner (practitioner or organization) | GET [base]/Patient?_include=Patient:general-practitioner | ||||||
| 2 | Payment details | Payer | Insurance information | GET [base]/Coverage?_include=Coverage:payor:Patient&_include=Coverage:payor:Organization | ||||||
| 3 | Treatment directives | TreatmentDirective | Known treatment directives | GET [base]/Consent?category=http://snomed.info/sct|11291000146105 | ||||||
| AdvanceDirective | Known advance directives | GET [base]/Consent?category=http://snomed.info/sct|11341000146107 | ||||||||
| 4 | Contact persons | ContactPerson | First relation/contact | see Patient | ||||||
| 5 | Functional status | FunctionalOrMentalStatus | Last known functional / mental status | GET [base]/Observation/$lastn?category=http://snomed.info/sct|118228005,http://snomed.info/sct|384821006
| ||||||
| 6 | Problems | Concern | All known problems | GET [base]/Condition | ||||||
| 7 | Social history | LivingSituation | Current living situation | GET [base]/Observation/$lastn?code=http://snomed.info/sct|365508006 | ||||||
| DrugUse | All known drug use | GET [base]/Observation?code=http://snomed.info/sct|228366006 | ||||||||
| AlcoholUse | All known alcohol use | GET [base]/Observation?code=http://snomed.info/sct|228273003 | ||||||||
| TobaccoUse | All known tobacco use | GET [base]/Observation?code=http://snomed.info/sct|365980008 | ||||||||
| NutritionAdvice | All known current dietary recommendations | GET [base]/NutritionOrder | ||||||||
| 8 | Alerts | Alert | All known alerts | GET [base]/Flag | ||||||
| 9 | Allergies | AllergyIntolerance | All known information regarding allergies | GET [base]/AllergyIntolerance | ||||||
| 10 | Medication | MedicationUse | Known medication use | GET [base]/MedicationStatement?category=urn:oid:2.16.840.1.113883.2.4.3.11.60.20.77.5.3|6&_include=MedicationStatement:medication | ||||||
| MedicationAgreement | Known medication agreements | GET [base]/MedicationRequest?category=http://snomed.info/sct|16076005&_include=MedicationRequest:medication | ||||||||
| AdministrationAgreement | Known administration agreements | GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&_include=MedicationDispense:medication
| ||||||||
| 11 | Medical aids | MedicalDevice | Known medical aids | GET [base]/DeviceUseStatement?_include=DeviceUseStatement:device | ||||||
| 12 | Vaccinations | Vaccination | Known vaccinations | GET [base]/Immunization?status=completed | ||||||
| 13 | Vital signs | BloodPressure | Last known blood pressure | GET [base]/Observation/$lastn?code=http://loinc.org|85354-9 | ||||||
| BodyWeight | Last known body weight | GET [base]/Observation/$lastn?code=http://loinc.org|29463-7 | ||||||||
| BodyHeight | Last known body height | GET [base]/Observation/$lastn?code=http://loinc.org|8302-2,http://loinc.org|8306-3,http://loinc.org|8308-9 | ||||||||
| 14 | Results | LaboratoryTestResult | Last known laboratory results per type | GET [base]/Observation/$lastn?category=http://snomed.info/sct|275711006&_include=Observation:related-target&_include=Observation:specimen | ||||||
| 15 | Procedures | Procedure | Known surgical procedures | GET [base]/Procedure?category=http://snomed.info/sct|387713003 | ||||||
| 16 | Encounters | Contact | Known hospital admissions (no outpatient contacts) | GET [base]/Encounter?class=http://hl7.org/fhir/v3/ActCode|IMP,http://hl7.org/fhir/v3/ActCode|ACUTE,http://hl7.org/fhir/v3/ActCode|NONAC | ||||||
| 17 | Planned care | PlannedCareActivityForTransfer | Known planned care activities |
GET [base]/ProcedureRequest?status=active GET [base]/ImmunizationRecommendation
GET [base]/MedicationDispense?category=http://snomed.info/sct|422037009&status=in-progress,preparation&_include=MedicationDispense:medication
GET [base]/DeviceRequest?status=active&_include=DeviceRequest:device GET [base]/Appointment?status=booked,pending,proposed | ||||||
| 18 | General practitioner | HealthProfessional | General Practitioner of the patient | see Patient |
- ↑ See Search URLs and search parameters for the interpretation of these search URLs
4.2 XIS: response message
The returned data to the PHR should conform to the profiles listed in #List_of_profiles.
4.3 The lastn operation
The following operation is needed for this use case.
The lastn query meets the common need for searching for the most recent or last n=number of observations for a subject. For example, retrieving the last 5 temperatures for a patient to view trends or fetching the most recent laboratory results or vital signs. The link will provide more detailed information and examples regarding this operation.
The FHIR STU3 specification is vague regarding the sorting mechanism of lastn. In FHIR R4 however, this has been clarified and can be read as follows: when using lastn, the effective[x] element is used for sorting of Observations, sorted from most recent to the oldest.
5 List of profiles
The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of BgZ or a MedMij context. An example of reuse of existing profiles is those of the patient administration resources and vital signs.
|
|
MedMij uses the FHIR Packaging mechanism. This conveniently bundles all profiles, terminology, example material and other conformance resources you need into a single archive, which can be downloaded or installed using the appropriate FHIR tooling. This version of the information standard uses the following packages:
Note: packages use Semantic Versioning. Other versions can be used at will as long as they have the same major.minor number or a minor number higher than the stated version. |
6 Release notes
Release notes can be found on the functional design page.