Zandbak/MM-440

MedMij:Vdraft Issuebox

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 StructureDefinitions.

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.

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 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 LaboratoryResults. 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 List of invocations

This FHIR implementation guide assumes that the PHR system is able to make a connection to the XIS that contains the patients BgZ information. It does not provide information on finding the right XIS nor does it provide information about security. These infrastructure and interface specifications are described in the 'MedMij Afsprakenstelsel' (Dutch).

4.1 Client - PHR

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 interaction can be performed by an HTTP GET or command as shown:

GET [base]/[type]/{?[parameters]{&_format=[mime-type]}}

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 are based on StructureDefinitions listed in this section.

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.

#	BgZ section	HCIM EN	Content	Search URL
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	MedicalAid	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	PlannedCareActivity	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

4.2 Server - XIS

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 lastn operation).

4.2.1 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 content SHALL conform to the StructureDefinition applicable for the specific HCIM request. The list of a StructureDefinitions relevant for this use case is shown in the following paragraph: List of StructureDefinitions

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.

In the case of a RESTful search, these parameters are encoded in the self-link in the bundle that is returned:

  <link>
    <relation value="self"/>
    <url value="http://example.org/Patient?identifier=[Patient-ID]/>
  </link>

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

4.2.2 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 a non-existent resource e.g. GET [base]/Observation?subject=101, where "101" does not exist
• A parameter may refer to an unknown code e.g. GET [base]/Observation?code=loinc|1234-1, where the LOINC 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

5 Interactions, operations, search parameters

5.1 Interactions

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

• Search

5.2 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.

5.3 Search parameters

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

Search parameter types:

• token
  • Including modifier 'in'
• reference

Search result parameters:

• _include

6 List of StructureDefinitions

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 are those of the patient administration resources and vital signs.

Section	ZIB NL	HCIM EN	FHIR resource	FHIR profile
1	Patient	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
2	Betaler	Payer	Coverage	http://nictiz.nl/fhir/StructureDefinition/zib-Payer
			Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization
			Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
3	BehandelAanwijzing	TreatmentDirective	Consent	http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentDirective
	Wilsverklaring	AdvanceDirective	Consent	http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective
4	Contactpersoon	ContactPerson	Patient.contact	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
5	FunctioneleOfMentaleStatus	FunctionalOrMentalStatus	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-FunctionalOrMentalStatus
6	Probleem	Problem	Condition	http://nictiz.nl/fhir/StructureDefinition/zib-Problem
7	Woonsituatie	LivingSituation	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-LivingSituation
	DrugsGebruik	DrugUse	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-DrugUse
	AlcoholGebruik	AlcoholUse	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-AlcoholUse
	TabakGebruik	TobaccoUse	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-TobaccoUse
	Voedingsadvies	NutritionAdvice	NutritionOrder	http://nictiz.nl/fhir/StructureDefinition/zib-NutritionAdvice
8	Alert	Alert	Flag	http://nictiz.nl/fhir/StructureDefinition/zib-Alert
9	AllergieIntolerantie	AllergyIntolerance	AllergyIntolerance	http://nictiz.nl/fhir/StructureDefinition/zib-AllergyIntolerance
10	MedicatieGebruik	MedicationUse	MedicationStatement	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse
		MedicationAgreement	MedicationRequest	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
		AdministrationAgreement	MedicationDispense	http://nictiz.nl/fhir/StructureDefinition/zib-AdministrationAgreement
11	MedischHulpmiddel	MedicalDevice	Device	http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct
			DeviceUseStatement	http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDevice
12	Vaccinatie	Vaccination	Immunization	http://nictiz.nl/fhir/StructureDefinition/zib-Vaccination
			ImmunizationRecommendation	http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
13	Bloeddruk	BloodPressure	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-BloodPressure
	Lichaamsewicht	BodyWeight	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-BodyWeight
	Lichaamsengte	BodyHeight	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-BodyHeight
14	LaboratoriumUitslag	LaboratoryTestResult	Observation	http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation
			Specimen	http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Specimen
15	Verrichting	Procedure	Procedure	http://nictiz.nl/fhir/StructureDefinition/zib-Procedure
16	Contact	Encounter	Encounter	http://nictiz.nl/fhir/StructureDefinition/zib-Encounter
17	GeplandeZorgActiviteit	PlannedCareActivity	ProcedureRequest	http://nictiz.nl/fhir/StructureDefinition/zib-ProcedureRequest
			MedicationDispense [ * ]	http://nictiz.nl/fhir/StructureDefinition/zib-AdministrationAgreement
			ImmunizationRecommendation	http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
			DeviceRequest	http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceRequest
			Appointment	http://nictiz.nl/fhir/StructureDefinition/eAfspraak-Appointment
18	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

7 Terminology, NamingSystems, Mappings

7.1 Terminology

Relevant value sets can be found using the ValueSet category. All resources can be downloaded in a .zip file in XML or JSON format. In the .zip file, the ValueSets are stored in the directory 'Valuesets'.

7.2 NamingSystems

Relevant NamingSystems can be found using the NamingSystem category.

7.3 Mappings

Relevant HCIM to FHIR ValueSet mappings can be found using the ConceptMap category. All profiles include HCIM mappings. HCIM concepts are mapped to the corresponding FHIR elements using the HCIMs concept id. The top of the StructureDefinition contains meta information regarding the HCIM mapping, such as the name and uri of the HCIM. In the StructureDefinition elements, the corresponding HCIM ID is given including the mapping meta information id.

This is illustrated in the following example:

<StructureDefinition>
    <id value="nl-core-patient" />
    .....
    <mapping>
        <identity value="hcim-patient-v3.1-2017EN"/>
        <uri value="https://zibs.nl/wiki/Patient-v3.1(2017EN)"/>
        <name value="HCIM Patient-v3.1(2017EN)"/>
    </mapping>
    .....
        <element id="Patient.name">
            <path value="Patient.name" />
            <short value="NameInformation" />
            <alias value="Naamgegevens" />
            <type>
                <code value="HumanName" />
                <profile value="http://fhir.nl/fhir/StructureDefinition/nl-core-humanname" />
            </type>
            <mapping>
                <identity value="hcim-patient-v3.1-2017EN"/>
                <map value="NL-CM:0.1.6"/>
            </mapping>
         </element>
     .....
</StructureDefinition>

8 Annex: Document history

8.1 Release notes

Release notes can be found on the functional design page.

8.2 Page history

Release	Date	Description
2019.01	11-03-2019	* MM-115 Solved inconsistency in the List of StructureDefinitions. Also we will no longer check PlannedCareActivityForTransfer for MedicationAdministration in section 17 Zorgplan, because we found it was unimplementable as-is. Presumed solution will come from a future HCIM release.
2019.01	11-03-2019	Publication of changes in version 2019.01, conform release notes Moved release notes to functional design page
2018.06	18-10-2018	Corrected SNOMED code in search url for FunctionalOrMentalStatus
2018.06	15-10-2018	Added version in title, and document history