MedMij:V2019.01 FHIR BGLZ

1 Introduction

This page provides the technical specification of the exchange of long-term healthcare information (Dutch: Basisgegevens Langdurige Zorg or BgLZ) based on a selection of Dutch Health Care Information Models. The specification is based on this functional design.

2 Actors involved

Actors		Systems		FHIR Capability Statements
Name	Description	Name	Description	Name	Description
Patient	The user of a personal healthcare enviorment.	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 BgLZ has similarities with the Basisgegevensset Zorg (BgZ) and Basisgegevens GGZ (GGZ) but is definitely different. These information standards use much of the same HCIM based FHIR profiles for exchanging information. Wherever possible every attempt is made to re-use profiles. The BgLZ use case also has unique profiles compared to the aforementioned use cases, such as OutcomeOfCare. In addition, it uses a CareTeam profile without an underlying HCIM. A second thing to note is that also the selection of requested information per HCIM may differentiate. For example, only a subset of LaboratoryResults or AllergyIntolerance is expected to be returned by a XIS. This page, which belongs to the BgLZ functional design, and related transactions provide details on the information that is expected to be exchanged.

Medication information is part of a good overview of patients in long-term healthcare. Retrieving medication information by a PHR is however out of scope for this information standard. A separate information standard, MedicationProcess, is intended to serve this purpose.

4 Use case: Retrieve BgLZ 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 Introduction

The retrieve BgLZ transaction is used by the PHR to retrieve long-term healthcare information from a XIS.

4.2 Actors

Transaction group	Transaction	Actor	Role
Retrieve BgLZ (PULL)	Retrieve BgLZ request	Patient (using a PHR)	Request long-term healthcare information from a XIS
	Retrieve BgLZ response	Healthcare professional (using a XIS)	Serves long-term healthcare information to a PHR

4.3 Invocations

4.3.1 PHR: request message

The PHR system requests the BgLZ using individual search interactions. The BgLZ consists of multiple FHIR resources with certain constraints. To obtain the patient's BgLZ, 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]{&_format=[mime-type]}}

The table below shows in the first four columns the BgLZ sections, the HCIMs that constitute those sections and the specific content of the BgLZ. The last column shows the FHIR search queries to obtain the BgLZ information. These queries and expected responses are based on StructureDefinitions listed in this section.

#	BgLZ Section	HCIM EN	Content	Search URL
1	Patient information	Patient	Identification, birthdate, gender, deceasedindicator, contact details, marital status, and general practitioner (practitioner or organization)	GET [base]/Patient?_include=Patient:general-practitioner
2	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
3	Contactperson	ContactPerson	First relation/contact	see Patient in Patient.contact
4	Problems	Problem	All known problems including diagnoses; no verification status	GET [base]/Condition
5	Allergies	AllergyIntolerance	A selection of information from all known allergies and intolerances. The ART-DECOR transaction specification describes the selection.	GET [base]/AllergyIntolerance
6	Results	LaboratoryTestResult	A selection of infromation from the last known clinical laboratory results per type. The ART-DECOR transaction specification describes the selection.	GET [base]/Observation/$lastn?category=http://snomed.info/sct|275711006&_include=Observation:related-target&_include=Observation:specimen
7	Procedures	Procedure	All procedures	GET [base]/Procedure
8	Goals and interventions * see the NoteBox above	NursingIntervention	NursingInterventions beloning to active problems	GET [base]/CarePlan?_include=CarePlan:activity-goal:Goal &_include=CarePlan:activity-outcomereference:Observation &_include=CarePlan:activity-medicaldevice:DeviceUseStatement &_include:recurse=DeviceUseStatement:device:Device
		TreatmentObjective	All treatment objectives beloning to NursingInterventions
		MedicalDevice	All MedicalDevices belonging to NursingInterventions; only product type and anatomical location
		OutcomeOfCare	Known treatment outcomes
9	Caresetting / CareTeam	HealthProfessional	General practitioner of the patient (see Patient.generalPractitioner) Primary practitioner - information of the primary care giver, no ID, adress/contact information Other practitioners - information of all practitioners given care to the patient, no ID, adress/contact information Healthcare provider - organization where care is given	GET [base]/CareTeam?_include=CareTeam:participant
		HealthcareProvider

4.3.2 XIS: response message

Important sections of the FHIR specification for a server in this use case are the RESTful API section the search section and operation section (for the nlast operation).

4.3.2.1 Response to resource requests

If the search succeeds, the server SHALL return a 200 OK HTTP status code and the returned content SHALL be a Bundle with type = searchset containing the results of the search as a collection of zero or more resources in a defined order. The returned resources SHALL conform to the StructureDefinition applicable for the specific HCIM request. The list of StructureDefinitions relevant for this use case is shown in the following paragraph: List of StructureDefinitions. All resources SHALL include their related StructureDefinition canonical URL in the meta.profile element in order to show compliance.

The result collection can be long, so servers may use paging. If they do, they SHALL use the method described below (adapted from RFC 5005 (Feed Paging and Archiving ) for breaking the collection into pages if appropriate. The server MAY also return an OperationOutcome resource within the searchset Bundle entries that contains additional information about the search; if one is sent it SHALL NOT include any issues with a fatal or error severity, and it SHALL be marked with a Bundle.entry.search.mode of outcome.

In order to allow the client to be confident about what search parameters were used as criteria by the server, the server SHALL return the parameters that were actually used to process the search. Applications processing search results SHALL check these returned values where necessary. For example, if the server did not support some of the filters specified in the search, a client might manually apply those filters to the retrieved result set, display a warning message to the user or take some other action. Link to the relevant FHIR specification: http://hl7.org/fhir/STU3/http.html#search

4.3.2.2 Handling errors

If the search fails (cannot be executed, not that there are no matches), the return value is a status code 4xx or 5xx with an OperationOutcome. An HTTP status code of 403 signifies that the server refused to perform the search, while other 4xx and 5xx codes signify that some sort of error has occurred. The HTTP status code 404 is returned if a XIS did not implement an endpoint used in a request by a PHR. When the search fails, a server SHOULD return an OperationOutcome detailing the cause of the failure. For example, in case of a not implemented FHIR endpoint, the OperationOutcome would state that the resource type is not supported. Note: an empty search result is not a failure.

Common HTTP Status codes returned on FHIR-related errors (in addition to normal HTTP errors related to security, header and content type negotiation issues):

• 400 Bad Request - search could not be processed or failed basic FHIR validation rules
• 401 Not Authorized - authorization is required for the interaction that was attempted
• 404 Not Found - resource type not supported, or not a FHIR end-point

In some cases, parameters may cause an error. For instance:

• A parameter may refer to an unknown code e.g. GET [base]/Observation?code=1234-1, where the code "1234-1" is not known to the server
• A parameter may refer to a time that is out of scope e.g. GET [base]/Condition?onset=le1995, where the system only has data going back to 2001
• A parameter may use an illegal or unacceptable modifier e.g. GET [base]/Condition?onset:text=1995, where the modifier cannot be processed by the server
• A date/time parameter may have incorrect format e.g. GET [base]/Condition?onset=23%20May%202009
• A parameter may be unknown or unsupported

Where the content of the parameter is syntactically incorrect, servers SHOULD return an error. However, where the issue is a logical condition (e.g. unknown subject or code), the server SHOULD process the search, including processing the parameter - with the result of returning an empty search set, since the parameter cannot be satisfied. In such cases, the search process MAY include an OperationOutcome in the search set that contains additional hints and warnings about the search process. This is included in the search results as an entry with search mode = outcome. Clients can use this information to improve future searches.

Link to relevant FHIR specification: http://hl7.org/fhir/STU3/search.html#errors

4.4 Interactions, operations, search parameters

4.4.1 Interactions

The following logical interactions are needed for the BgLZ use case:

• Search

4.4.2 Operations

The following operation is needed for this use case.

• Last N Observations Query

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.

4.4.3 Search parameters

The following search parameter types and search result parameters need to be supported for this use case.

Search parameter types:

• token
• reference

Search result parameters:

• _include
  • Including modifier 'recurse'

The following custom search parameters are defined for this use case:

• http://nictiz.nl/fhir/SearchParameter/careplan-activity-goal
• http://nictiz.nl/fhir/SearchParameter/careplan-activity-outcomereference
• http://nictiz.nl/fhir/SearchParameter/careplan-medicaldevice

4.5 List of StructureDefinitions

The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of BgLZ or a MedMij context.

Zib NL	HCIM EN	FHIR Resource	FHIR Profile
Patiënt	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
BehandelAanwijzing	TreatmentDirective	Consent	http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentDirective
Wilsverklaring	AdvanceDirective	Consent	http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective
Probleem	Problem	Condition	http://nictiz.nl/fhir/StructureDefinition/zib-Problem
AllergieIntolerantie	AllergyIntolerance	AllergyIntolerance	http://nictiz.nl/fhir/StructureDefinition/zib-AllergyIntolerance
LaboratoriumUitslag	LaboratoryTestResult	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation
Verrichting	Procedure	Procedure	http://nictiz.nl/fhir/StructureDefinition/zib-Procedure
VerpleegkundigeInterventie *	NursingIntervention *	CarePlan	http://fhir.nl/fhir/StructureDefinition/nl-core-careplan
Behandeldoel	TreatmentObjective
MedischHulpmiddel	MedicalDevice
UitkomstVanZorg	OutcomeOfCare
Zorgverlener	HealthProfessional	Practitioner	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
		PractitionerRole	http://fhir.nl/fhir/StructureDefinition/nl-core-practitionerrole
Zorgaanbieder	HealthcareProvider	Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization
-	-	CareTeam	http://fhir.nl/fhir/StructureDefinition/nl-core-careteam

* The 2018 release of the HCIM NursingIntervention is used because the 2017 release is not suitable. The functional design page provides more information. In addition, the CarePlan resource is used to transfer the HCIM NursingIntervention. The BgLZ does not use the Procedure resource for HCIM NursingIntervention.

Example instances of FHIR resources can be found on Simplifier. Please note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of any information standard.

4.6 Terminology, NamingSystems, Mappings

Relevant ValueSets, NamingSystems and ConceptMaps can be found in the packages referenced in the List of StructureDefinitions section.

The HCIM ValueSets used in the profiles are included in the package (or one of its dependencies). When a FHIR core ValueSet must be used instead of an HCIM ValueSet, a FHIR ConceptMap resource is provided to map the values between the two sets. An explanation about mappings can be found at in the overarching principles.

5 Release notes

Release notes can be found on the functional design page.