MedMij:Vprepub-2020.01/FHIR GP Data: verschil tussen versies

Uit informatiestandaarden
Naar navigatie springen Naar zoeken springen
k (MM-421 Add missing gp-Encounter listing)
(MM-2136: Make clear that the optional "periodOfUse" is about the source data, not the query parameter)
 
(10 tussenliggende versies door 3 gebruikers niet weergegeven)
Regel 1: Regel 1:
 
__NUMBEREDHEADINGS__
 
__NUMBEREDHEADINGS__
{{DISPLAYTITLE:MedMij FHIR Implementation Guide GP Patient Data {{VersieInfo|Huisartsgegevens|release=Vprepub}}}}
+
{{DISPLAYTITLE:MedMij FHIR Implementation Guide GP Patient Data {{VersieInfo|Huisartsgegevens}}}}
{{MedMij:Vprepub/Issuebox_FHIR_IG}}
+
{{MedMij:Vprepub-2020.01/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:Vprepub/OntwerpHuisartsgegevens|Functioneel]]                 
+
circle 1013 224 212 [[MedMij:Vprepub-2020.01/OntwerpHuisartsgegevens|Functioneel]]                 
circle 1787 230 212 [[MedMij:Vprepub/FHIR_IG|Technisch]]                 
+
circle 1787 230 212 [[MedMij:Vprepub-2020.01/FHIR_IG|Technisch]]                 
 
desc none                     
 
desc none                     
 
</imagemap>
 
</imagemap>
Regel 15: Regel 15:
  
 
==Introduction==
 
==Introduction==
[[Bestand:Functioneel-02.png|link=MedMij:Vprepub/Ontwerpen |100px|rechts|Functional design|Go to functional design]]
+
[[Bestand:Functioneel-02.png|link=MedMij:Vprepub-2020.01/Ontwerpen |100px|rechts|Functional design|Go to functional design]]
  
The input document "[[MedMij:Vprepub/OntwerpHuisartsgegevens#richtlijn-huisarts-patient|Richtlijn online inzage in het H-EPD door patiënt]]" (Dutch) described online access of GP data by patients. The use case evolves around a GP specific Patient Data that consists of 10 sections plus the patient and the healthcare provider (GP). These sections correspond to the "[[MedMij:Vprepub/OntwerpHuisartsgegevens#his-referentiemodel-2016|HIS referentiemodel Publieksversie 2016]]" (Dutch). ''HIS referentiemodel'' is the GP information system reference model (GP-IS-RM).
+
The input document "[[MedMij:Vprepub-2020.01/OntwerpHuisartsgegevens#richtlijn-huisarts-patient|Richtlijn online inzage in het H-EPD door patiënt]]" (Dutch) described online access of GP data by patients. The use case evolves around a GP specific Patient Data that consists of 10 sections plus the patient and the healthcare provider (GP). These sections correspond to the "[[MedMij:Vprepub-2020.01/OntwerpHuisartsgegevens#his-referentiemodel-2016|HIS referentiemodel Publieksversie 2016]]" (Dutch). ''HIS referentiemodel'' is the GP information system reference model (GP-IS-RM).
  
 
Some but not all sections in the GP Patient Data correspond to Health and Care Information Models ([https://zibs.nl/wiki/HCIM_Mainpage HCIMs] (English) or [https://zibs.nl/wiki/ZIB_Hoofdpagina zibs] (Dutch)). A joint initiative project between [http://www.nictiz.nl Nictiz] and the Dutch GP association [https://www.nhg.org NHG] is underway to analyse the relationship between the GP-IS-RM and the HCIMs and propose updates where needed. This analysis will not yield results before 2019. This specification thus predates the analysis, and will updated accordingly moving forward.
 
Some but not all sections in the GP Patient Data correspond to Health and Care Information Models ([https://zibs.nl/wiki/HCIM_Mainpage HCIMs] (English) or [https://zibs.nl/wiki/ZIB_Hoofdpagina zibs] (Dutch)). A joint initiative project between [http://www.nictiz.nl Nictiz] and the Dutch GP association [https://www.nhg.org NHG] is underway to analyse the relationship between the GP-IS-RM and the HCIMs and propose updates where needed. This analysis will not yield results before 2019. This specification thus predates the analysis, and will updated accordingly moving forward.
Regel 23: Regel 23:
 
This page will elaborate further on the HL7 FHIR details needed to exchange the GP Patient Data information using FHIR.
 
This page will elaborate further on the HL7 FHIR details needed to exchange the GP Patient Data information using FHIR.
  
'''Note''': This implementation guide builds on the general guidelines described in the [[MedMij:Vprepub/FHIR_IG#Use case overarching principles|use case overarching principles]].
+
'''Note''': This implementation guide builds on the general guidelines described in the [[MedMij:Vprepub-2020.01/FHIR_IG#Use case overarching principles|use case overarching principles]].
  
 
==Actors involved==
 
==Actors involved==
Regel 65: Regel 65:
 
<code>GET [base]/[type]{?[parameters]}</code>
 
<code>GET [base]/[type]{?[parameters]}</code>
  
The table below shows in the first four columns the GP Patient Data sections, the GP-IS-RM sections / HCIMs that constitute those sections and the specific content of the GP Patient Data. The last column shows the FHIR search queries to obtain the GP Patient Data information. These queries are based on StructureDefinitions listed in [[#List_of_StructureDefinitions| this section]]. As noted in the [[#Introduction|introduction]], the associated HCIMs are ahead of a separate joint initiative project that aims to analyse and harmonize this further.
+
The table below shows in the first four columns the GP Patient Data sections, the GP-IS-RM sections / HCIMs that constitute those sections and the specific content of the GP Patient Data. The last column shows the FHIR search queries to obtain the GP Patient Data information. These queries are based on profiles listed in [[#List_of_profiles|this section]]. As noted in the [[#Introduction|introduction]], the associated HCIMs are ahead of a separate joint initiative project that aims to analyse and harmonize this further.
  
 
{| class="wikitable collapsible" cellpadding="10"
 
{| class="wikitable collapsible" cellpadding="10"
Regel 74: Regel 74:
 
! 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:Vprepub/FHIR_IG#Search_URLs_and_search_parameters|Search URLs and search parameters]] for the interpretation of these search URLs</ref>
+
! style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:left;  background-color: #E3E3E3 width:10px"| Search URL<ref>See [[MedMij:Vprepub-2020.01/FHIR_IG#Search_URLs_and_search_parameters|Search URLs and search parameters]] for the interpretation of these search URLs</ref>
 
|-
 
|-
 
| style="background-color: white;vertical-align:top;"| 1
 
| style="background-color: white;vertical-align:top;"| 1
Regel 120: Regel 120:
 
| style="vertical-align:top;"|Current medication
 
| style="vertical-align:top;"|Current medication
 
| style="vertical-align:top;"|[https://zibs.nl/wiki/MedicationAgreement-v1.0(2017EN) MedicationAgreement v1.0 (2017)]
 
| style="vertical-align:top;"|[https://zibs.nl/wiki/MedicationAgreement-v1.0(2017EN) MedicationAgreement v1.0 (2017)]
| style="vertical-align:top;"|MedicationAgreement <br/>The prescriber proposed use of medication that the patient agrees with. The agreement may signal starting, repeating, updating or stopping the medication. The list of MedicationAgreements is also known as the list of medication the patient is '''currently''' using. Note that current means that the period of use is still active. This is conveyed in the MedicationRequest.extension periodOfUse. This may or may not me populated. If it is not, the Medicationagreement is assumed to be current. The search parameter {{Simplifier|http://nictiz.nl/fhir/SearchParameter/Medications-periodofuse|nictiz.fhir.nl.stu3.zib2017|title=periodofuse}} allows filtering for current medicationagreements
+
| style="vertical-align:top;"|MedicationAgreement <br/>The prescriber proposed use of medication that the patient agrees with. The agreement may signal starting, repeating, updating or stopping the medication. The list of MedicationAgreements is also known as the list of medication the patient is '''currently''' using. Note that "currently" means that the period of use is still active. This is conveyed in the MedicationRequest extension {{fhir|periodOfUse}}. This extension may or may not be populated. If it is not, the Medicationagreement is assumed to be current. The search parameter {{Simplifier|http://nictiz.nl/fhir/SearchParameter/Medications-periodofuse|nictiz.fhir.nl.stu3.zib2017|title=periodofuse}} allows filtering for current MedicationAgreements.
 
| style="vertical-align:top;"|<pre>GET [base]/MedicationRequest?periodofuse=ge[today]&category=http://snomed.info/sct|16076005&_include=MedicationRequest:medication</pre>
 
| style="vertical-align:top;"|<pre>GET [base]/MedicationRequest?periodofuse=ge[today]&category=http://snomed.info/sct|16076005&_include=MedicationRequest:medication</pre>
 
|-
 
|-
Regel 138: Regel 138:
 
| style="background-color: white;vertical-align:top;" rowspan="9"| Diagnostic and lab results
 
| style="background-color: white;vertical-align:top;" rowspan="9"| Diagnostic and lab results
 
| style="background-color: white;vertical-align:top;"| [https://zibs.nl/wiki/LaboratoryTestResult-v4.0(2017EN) LaboratoryTestResult v4.0 (2017)]
 
| style="background-color: white;vertical-align:top;"| [https://zibs.nl/wiki/LaboratoryTestResult-v4.0(2017EN) LaboratoryTestResult v4.0 (2017)]
| style="background-color: white;vertical-align:top;" rowspan="9"|A lab test is an objectifiable diagnostic procedure. The result is the outcome of the procedure. Lab tests include vital signs like blood pressure, weight and lab results like ferro in blood.<br/><br/>Note that GP (lab) results are normally coded using [https://referentiemodel.nhg.org/tabellen/nhg-tabel-45-diagnostische-bepalingen NHG Tabel 45]. While some of these codes might be convertible to LOINC or SNOMED CT, this is '''not''' expected at present. Bridging code systems between primary and secondary care is part of a larger national discussion<br/><br/>Note that the date parameter is optional and needs calculation, e.g. current-date() - 14 months. The business rules in the [[MedMij:Vprepub/OntwerpHuisartsgegevens#richtlijn-huisarts-patient|guide lines]] determine the maximum range for the returned results. If the date parameter is omitted, the maximum range is assumed
+
| style="background-color: white;vertical-align:top;" rowspan="9"|A lab test is an objectifiable diagnostic procedure. The result is the outcome of the procedure. Lab tests include vital signs like blood pressure, weight and lab results like ferro in blood.<br/><br/>Note that GP (lab) results are normally coded using [https://referentiemodel.nhg.org/tabellen/nhg-tabel-45-diagnostische-bepalingen NHG Tabel 45]. While some of these codes might be convertible to LOINC or SNOMED CT, this is '''not''' expected at present. Bridging code systems between primary and secondary care is part of a larger national discussion<br/><br/>Note that the date parameter is optional and needs calculation, e.g. current-date() - 14 months. The business rules in the [[MedMij:Vprepub-2020.01/OntwerpHuisartsgegevens#richtlijn-huisarts-patient|guide lines]] determine the maximum range for the returned results. If the date parameter is omitted, the maximum range is assumed
 
| style="background-color: white;" rowspan="9"| <pre>GET [base]/Observation?code=https://referentiemodel.nhg.org/tabellen/nhg-tabel-45-diagnostische-bepalingen|&_include=Observation:related-target&_include=Observation:specimen&date=ge2017-01-01</pre>
 
| style="background-color: white;" rowspan="9"| <pre>GET [base]/Observation?code=https://referentiemodel.nhg.org/tabellen/nhg-tabel-45-diagnostische-bepalingen|&_include=Observation:related-target&_include=Observation:specimen&date=ge2017-01-01</pre>
 
|-
 
|-
Regel 162: Regel 162:
 
| Information from an encounter, recorded in free text using the SOAP structure. The acronym SOAP stands for Subjective, Objective, Assessment and Plan. The E entry contains the consultation conclusion and the P entry contains potential next steps.<br/><br/>Note that the profile for SOAP entries is yet to be created and the  code system value is preliminary
 
| Information from an encounter, recorded in free text using the SOAP structure. The acronym SOAP stands for Subjective, Objective, Assessment and Plan. The E entry contains the consultation conclusion and the P entry contains potential next steps.<br/><br/>Note that the profile for SOAP entries is yet to be created and the  code system value is preliminary
 
| <pre>GET [base]/Composition?type=http://loinc.org|67781-5</pre>
 
| <pre>GET [base]/Composition?type=http://loinc.org|67781-5</pre>
{{NoteBox|The underlying guideline does not explicitly mention encounters nor partial encounters (Dutch: ''Deelcontacten''), but journal entries are normally 'grouped' as encounters based on the entry complaint (journal entry type Subjective). If multiple entry complaints have been discussed based during a single encounter, these are regarded as partial encounters.  
+
{{NoteBox|The underlying guideline does not explicitly mention encounters nor partial encounters (Dutch: ''deelcontacten''), but journal entries are normally 'grouped' as encounters based on the entry complaint (journal entry type Subjective). If multiple entry complaints have been discussed based during a single encounter, these are regarded as partial encounters.  
  
The expectation of each EncounterReport (Composition) is that it combines the journal entries that constitute a partial encounter. If there is just one issue discussed during the encounter, there is only one EncounterReport. If there is more than one partial contact, there could be multiple EncounterReports pointing to the same encounter.  
+
The expectation of each encounter report (Composition) is that it combines the journal entries that constitute a partial encounter. If there is just one issue discussed during the encounter, there is only one encounter report. If there is more than one partial contact, there could be multiple encounter reports pointing to the same encounter.  
  
Note that while FHIR supports Encounters being part of other Encounters, this does not reflect how GP systems are organized. Encounter parts do not not have individual properties to manage and act as a kind of virtual compartment within the Encounter.}}
+
Note that while FHIR supports Encounter resources being part of other Encounter resources, this does not reflect how GP systems are organized. Encounter parts do not not have individual properties to manage and act as a kind of virtual compartment within the encounter.}}
 
|-
 
|-
 
| style="background-color: white;vertical-align:top;"| 13
 
| style="background-color: white;vertical-align:top;"| 13
Regel 179: Regel 179:
  
 
===Server - XIS===
 
===Server - XIS===
The returned data to the PHR should conform to the profiles listed in [[#List_of_StructureDefinitions]].
+
The returned data to the PHR should conform to the profiles listed in [[#List_of_profiles]].
  
 
===Custom search parameters===
 
===Custom search parameters===
Regel 189: Regel 189:
  
 
In the case of a RESTful search, these parameters are encoded in the self link in the bundle that is returned:
 
In the case of a RESTful search, these parameters are encoded in the self link in the bundle that is returned:
<pre>
+
<syntaxhighlight lang="xml">
  <link>
+
<link>
    <relation value="self"/>
+
  <relation value="self"/>
    <url value="http://example.org/Patient?identifier=[Patient-ID]/>
+
  <url value="http://example.org/Patient?identifier=[Patient-ID]/>
  </link>
+
</link>
</pre>
+
</syntaxhighlight>
  
 
Link to the relevant FHIR specification: http://hl7.org/fhir/STU3/http.html#search
 
Link to the relevant FHIR specification: http://hl7.org/fhir/STU3/http.html#search
Regel 253: Regel 253:
 
<nowiki>*</nowiki> This SearchParameter searches on the FHIR DataType Period in the PeriodOfUse extension, which is added to profiles on MedicationRequest and MedicationDispense resources. Clients use date parameter searches as described by the [http://hl7.org/fhir/stu3/search.html#date FHIR specification]. Servers are expected to take the [http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse-Duration MedicationUse-Duration extension] into account when processing a client's search. This means that either a Period.start + Period.end or Period.start + Duration is used to determine the search results. To illustrate the expected behavior: if a Period.start and a Duration is known, but not the Period, the Duration should be added to the Period.start date to calculate the Period.end. The calculated Period.end date is then used to determine the search results.
 
<nowiki>*</nowiki> This SearchParameter searches on the FHIR DataType Period in the PeriodOfUse extension, which is added to profiles on MedicationRequest and MedicationDispense resources. Clients use date parameter searches as described by the [http://hl7.org/fhir/stu3/search.html#date FHIR specification]. Servers are expected to take the [http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse-Duration MedicationUse-Duration extension] into account when processing a client's search. This means that either a Period.start + Period.end or Period.start + Duration is used to determine the search results. To illustrate the expected behavior: if a Period.start and a Duration is known, but not the Period, the Duration should be added to the Period.start date to calculate the Period.end. The calculated Period.end date is then used to determine the search results.
  
==List of StructureDefinitions==
+
==List of profiles==
 
The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of GP Patient Data or a MedMij context. An example for reuse of existing profiles are 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 GP Patient Data or a MedMij context. An example for reuse of existing profiles are those of the patient administration resources and vital signs.
 
+
{{MedMij:Vprepub-2020.01/NoteBoxPackage|p1=nictiz.fhir.nl.stu3.zib2017|v1Min=2.0.0}}
{{MedMij:NoteBoxPackage|p1=nictiz.fhir.nl.stu3.zib2017}}
 
 
 
 
{| class="wikitable collapsible" cellpadding="10"
 
{| class="wikitable collapsible" cellpadding="10"
 
! style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:center; border: 1px solid black;"  colspan="6" | Bijlage 1 Richtlijn Online inzage in het H-EPD door patiënt
 
! style="background-color: #4AB8A7; color: white; font-weight: bold; text-align:center; border: 1px solid black;"  colspan="6" | Bijlage 1 Richtlijn Online inzage in het H-EPD door patiënt
Regel 348: Regel 346:
 
| {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/gp-Encounter|nictiz.fhir.nl.stu3.zib2017}}
 
| {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/gp-Encounter|nictiz.fhir.nl.stu3.zib2017}}
 
|}
 
|}
{{Sjabloon:Voorbeelden}}
+
===Referencing encounters and episodes===
 
+
During early testing of the published information standard, an omission was found. Any journal entry or other activity, and in some cases medication agreement and diagnostic results is associated with an encounter (Encounter resource in FHIR), but an additional association with one or more episodes (EpisodeOfCare in FHIR) is also normal GP practice. However, it is not possible to do this natively in the currently used FHIR version STU3: many resources define the element {{fhir|.context}} (Encounter <nowiki>|</nowiki> EpisodeOfCare), but restricts its cardinality to 0..1, meaning that a resource can be connected to either an Encounter or EpisodeOfCare resource, but not both.
==Terminology, NamingSystems, Mappings==
 
 
 
===Terminology===
 
Relevant value sets can be found [https://simplifier.net/NictizSTU3-Zib2017/~resources?category=ValueSet here]. All resources can be downloaded in a .zip in XML or JSON format. In the .zip, the value sets are stored in the directory 'value sets'.
 
 
 
===NamingSystems===
 
Relevant NamingSystems can be found [https://simplifier.net/NictizSTU3-Zib2017/~resources?category=NamingSystem here].
 
  
===Mappings===
+
The recommendation is to use {{fhir|.context}} for associating the Encounter, not the EpisodeOfCare. This approach aligns with the changes in FHIR version R4, where the {{fhir|.context}} element is replaced by {{fhir|.encounter}} to support just a reference to an Encounter resource. EpisodeOfCare resource can be referenced through a new extension published in the spring of 2021 (package 2.1.1): {{Simplifier|http://nictiz.nl/fhir/StructureDefinition/extension-context-nl-core-episodeofcare|nictiz.fhir.nl.stu3.zib2017}}.
A FHIR ConceptMap resource is provided when a FHIR value set is used instead of a HCIM value set. A ConceptMap maps the values between the two value sets. These ConceptMaps can be found [https://simplifier.net/NictizSTU3-Zib2017/~resources?category=ConceptMap here].
 
  
An explanation about mappings can be found at [[MedMij:Vprepub/FHIR_IG#Mapping_of_coded_concepts|Mapping of coded concepts]].
+
Compatibility note: systems that went in production before this new extension was published will not be able to interpret it, unless they update for it. These systems will ignore the extension and read - as specified - the {{fhir|.context}} which is normally claimed by a reference to Encounter. Updated and newer systems may now anticipate episode associations on journal entries, diagnostic results, medication agreements and potential other encounter activities, as applicable. For more details, please see [https://bits.nictiz.nl/browse/MM-1521 issue MM-1521].
  
 
=Release notes=
 
=Release notes=
Release notes can be found on the [[MedMij:Vprepub/OntwerpHuisartsgegevens#Release_notes| functional design page]].
+
Release notes can be found on the [[MedMij:Vprepub-2020.01/OntwerpHuisartsgegevens#Release_notes| functional design page]].

Huidige versie van 21 jun 2021 om 08:03


Naar medmij.nl
GP Patient Data
AfsprakenstelselFunctioneelTechnischAfspraken-Functioneel-Technisch

1 Introduction

Go to functional design

The input document "Richtlijn online inzage in het H-EPD door patiënt" (Dutch) described online access of GP data by patients. The use case evolves around a GP specific Patient Data that consists of 10 sections plus the patient and the healthcare provider (GP). These sections correspond to the "HIS referentiemodel Publieksversie 2016" (Dutch). HIS referentiemodel is the GP information system reference model (GP-IS-RM).

Some but not all sections in the GP Patient Data correspond to Health and Care Information Models (HCIMs (English) or zibs (Dutch)). A joint initiative project between Nictiz and the Dutch GP association NHG is underway to analyse the relationship between the GP-IS-RM and the HCIMs and propose updates where needed. This analysis will not yield results before 2019. This specification thus predates the analysis, and will updated accordingly moving forward.

This page will elaborate further on the HL7 FHIR details needed to exchange the GP Patient Data information using FHIR.

Note: This implementation guide builds on the general guidelines described in the use case overarching principles.

2 Actors involved

Persons Systems FHIR Capability Statements
Name Description Name Description Name Description
Patient The user of a personal healthcare environment. PHR Personal health record Verwijzing.png CapabilityStatement: Client GP Patient Data client requirements
Healthcare professional The user of a XIS XIS Healthcare information system Verwijzing.png CapabilityStatement: Server GP Patient Data server requirements

3 Boundaries and Relationships

The GP Patient Data use case has similarities and differences with other use cases such as the BgZ, Medication Process, Vital Signs and Lab Results. These use cases use much of the same HCIM based FHIR profiles for exchanging information. Wherever possible every attempt is made to re-use the profiles as used in the BgZ. The GP Patient Data also has a few unique profiles compared to the aforementioned use cases. A second thing to note is that while the selection criteria of certain sections like lab do not match, this does not affect the response profiles. For example it is irrelevant for the response profile lab if you request the 'latest lab result' or 'every result since date X'.

4 List of invocations

Go to Afsprakenstelsel

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 Client - PHR

The PHR system requests the GP Patient Data using individual search interactions. The search interaction searches the current resources based on some filter criteria. The interactions are performed by an HTTP GET or command as shown:

GET [base]/[type]{?[parameters]}

The table below shows in the first four columns the GP Patient Data sections, the GP-IS-RM sections / HCIMs that constitute those sections and the specific content of the GP Patient Data. The last column shows the FHIR search queries to obtain the GP Patient Data information. These queries are based on profiles listed in this section. As noted in the introduction, the associated HCIMs are ahead of a separate joint initiative project that aims to analyse and harmonize this further.

Bijlage 1 Richtlijn Online inzage in het H-EPD door patiënt
# GP Patient Data Section HCIM EN Content Search URL[1]
1 General Practitioner/Practice HealthProfessional v3.1 (2017)
HealthcareProvider v3.1 (2017)
The GP or GP practice that originates the patient data.
see Patient

Note: a separate query for General Practitioner/Practice is not required as this data is attached in context to the Patient resource.

2 Patient Patient v3.1 (2017) De patient data of the patient the data is for. Note that retrieving patient data separately may not be supported by GP systems in some circumstances. Patient data will however be part of the other responses in that case.
GET [base]/Patient?_include=Patient:general-practitioner

Note: a separate query for Patient may not be necessary for clients or supported by servers as this data is attached in context to every other (clinical) resource.

3 Episodes A health concern like a complaint of illness, that may change in nature as diagnoses are made and/or the illness develops.
GET [base]/EpisodeOfCare

A server MAY implement inclusion of associated Flag resources indicating that the GP has added an attention value to this episode. The reference from the Flag to the EpisodeOfCare is handled though Flag.extension(ConcernReference). For this reason, it is not possible for clients to request this information explicitly using _include or _revInclude parameters. Note that attention flags on a an episode are aimed at the GP, not at the patient.

4 Episodes with alert flag Episodes may have an associated alert signaling extra attention to the episode is requested. The alert flag may stay active even if after closing the episode, if the user deems it important to stay aware.
5 Open and closed episodes Episodes may be open (currently active) or closed (no longer active).
6 Treatment Procedure on the patient targeting the patients health situation. E.g. operative and (severe) procedures like radiation or chemotherapy. TODO: No HCIM. GP systems do not yet export this info.
7 Prophylaxis en precaution Prophylaxis and precaution contain precautionary measures required for or to prevent certain medical conditions. See NHG Tabel 56 TODO: No HCIM. GP systems do not yet export this info. Unclear if it'll be anything beyond the Table 56 code (id, time, author, text?)
8 Current medication MedicationAgreement v1.0 (2017) MedicationAgreement
The prescriber proposed use of medication that the patient agrees with. The agreement may signal starting, repeating, updating or stopping the medication. The list of MedicationAgreements is also known as the list of medication the patient is currently using. Note that "currently" means that the period of use is still active. This is conveyed in the MedicationRequest extension periodOfUse. This extension may or may not be populated. If it is not, the Medicationagreement is assumed to be current. The search parameter periodofuse allows filtering for current MedicationAgreements.
GET [base]/MedicationRequest?periodofuse=ge[today]&category=http://snomed.info/sct|16076005&_include=MedicationRequest:medication
9 Medication intolerance AllergyIntolerance v3.1 (2017) A medication intolerance concerns the intolerance of a patient for a specific drug, substance or substance group, that needs to be taken into account when prescribing, dispensing or administering medication.
GET [base]/AllergyIntolerance?category=medication
10 Correspondence Incoming: an incoming letter about a patient, recorded as such in the patients medical record.
Outbound: a letter created by a healthcare professional for a third party healthcare professional.
TODO: No HCIM. GP systems do not yet export this info. For PDF(/A) based correspondence it is possible to turn to the relevant information standard for that type of data.
11 Diagnostic and lab results LaboratoryTestResult v4.0 (2017) A lab test is an objectifiable diagnostic procedure. The result is the outcome of the procedure. Lab tests include vital signs like blood pressure, weight and lab results like ferro in blood.

Note that GP (lab) results are normally coded using NHG Tabel 45. While some of these codes might be convertible to LOINC or SNOMED CT, this is not expected at present. Bridging code systems between primary and secondary care is part of a larger national discussion

Note that the date parameter is optional and needs calculation, e.g. current-date() - 14 months. The business rules in the guide lines determine the maximum range for the returned results. If the date parameter is omitted, the maximum range is assumed
GET [base]/Observation?code=https://referentiemodel.nhg.org/tabellen/nhg-tabel-45-diagnostische-bepalingen|&_include=Observation:related-target&_include=Observation:specimen&date=ge2017-01-01
BloodPressure v3.1 (2017)
BodyHeight v3.1 (2017)
BodyTemperature v3.1 (2017)
BodyWeight v3.1 (2017)
GeneralMeasurement v3.0 (2017)
HeartRate v3.1 (2017)
O2Saturation v3.1(2017)
PulseRate v3.1(2017)
12 E- and P-journal entries of the SOAP (EN) or SOEP (NL) structure - recorded after introduction of online access Information from an encounter, recorded in free text using the SOAP structure. The acronym SOAP stands for Subjective, Objective, Assessment and Plan. The E entry contains the consultation conclusion and the P entry contains potential next steps.

Note that the profile for SOAP entries is yet to be created and the code system value is preliminary
GET [base]/Composition?type=http://loinc.org|67781-5
13 Encounters Encounter v3.1(2017) Encounters are expected to have at least an identifier, a type, a date possibly with start/end times, a responsible GP, and potentially an alternative performer such as an out-of-hour-services colleague (Dutch: waarnemer or triagist). Other things that could be recorded against an Encounter, such as the appointment, people escorting the patient (relatives, translator, neighbor) are not normally communicated.

Minimum expectation for returned Encounters is that this query should yield Encounters being referred to from other parts of the information standard.

GET [base]/Encounter
  1. See Search URLs and search parameters for the interpretation of these search URLs

4.2 Server - XIS

The returned data to the PHR should conform to the profiles listed in #List_of_profiles.

4.3 Custom search parameters

The custom search parameter Medications-periodofuse searches on the FHIR datatype Period in the PeriodOfUse extension, which is added to profiles on MedicationRequest and MedicationDispense. Clients use date parameter searches as described by the FHIR specification. Servers are expected to take the MedicationUse-Duration extension into account when processing a client's search. This means that either a Period.start + Period.end or Period.start + Duration is used to determine the search results.

To illustrate the expected behavior: if a Period.start and a Duration are known, but not the Period, the Duration should be added to the Period.start date to calculate Period.end. The calculated Period.end date is then used to determine the search results.

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

4.3.1 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 GP Patient Data use case:

5.2 Operations

There are no operations required to support this use case

5.3 Search parameters

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

Search parameter types:

Search result parameters:

* This SearchParameter searches on the FHIR DataType Period in the PeriodOfUse extension, which is added to profiles on MedicationRequest and MedicationDispense resources. Clients use date parameter searches as described by the FHIR specification. Servers are expected to take the MedicationUse-Duration extension into account when processing a client's search. This means that either a Period.start + Period.end or Period.start + Duration is used to determine the search results. To illustrate the expected behavior: if a Period.start and a Duration is known, but not the Period, the Duration should be added to the Period.start date to calculate the Period.end. The calculated Period.end date is then used to determine the search results.

6 List of profiles

The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of GP Patient Data or a MedMij context. An example for reuse of existing profiles are those of the patient administration resources and vital signs.

Bijlage 1 Richtlijn Online inzage in het H-EPD door patiënt
Section Zib NL HCIM EN FHIR Resource URL Profile
1 Zorgverlener HealthProfessional http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
Zorgaanbieder HealthcareProvider Organization http://fhir.nl/fhir/StructureDefinition/nl-core-organization
2 Patiënt Patient Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient
3 EpisodeOfCare http://nictiz.nl/fhir/StructureDefinition/zib-Alert
http://fhir.nl/fhir/StructureDefinition/nl-core-episodeofcare
4
5
8 MedicatieAfspraak MedicationAgreement MedicationRequest http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
9 AllergieIntolerantie AllergyIntolerance AllergyIntolerance http://nictiz.nl/fhir/StructureDefinition/zib-AllergyIntolerance
11 LaboratoriumUitslag LaboratoryTestResult Observation http://nictiz.nl/fhir/StructureDefinition/gp-DiagnosticResult (NHG Table 45 codes of type D)
http://nictiz.nl/fhir/StructureDefinition/gp-LaboratoryResult (NHG Table 45 codes of type L)
Bloeddruk BloodPressure
Lichaamslengte BodyHeight
Lichaamstemperatuur BodyTemperature
Lichaamsgewicht BodyWeight
AlgemeneMeting GeneralMeasurement
Harfrequentie HeartRate
O2Saturatie O2Saturation
Polsfrequentie PulseRate
12 Composition
Observation
http://nictiz.nl/fhir/StructureDefinition/gp-EncounterReport
http://nictiz.nl/fhir/StructureDefinition/gp-JournalEntry
13 Contact Encounter Encounter http://nictiz.nl/fhir/StructureDefinition/gp-Encounter

6.1 Referencing encounters and episodes

During early testing of the published information standard, an omission was found. Any journal entry or other activity, and in some cases medication agreement and diagnostic results is associated with an encounter (Encounter resource in FHIR), but an additional association with one or more episodes (EpisodeOfCare in FHIR) is also normal GP practice. However, it is not possible to do this natively in the currently used FHIR version STU3: many resources define the element .context (Encounter | EpisodeOfCare), but restricts its cardinality to 0..1, meaning that a resource can be connected to either an Encounter or EpisodeOfCare resource, but not both.

The recommendation is to use .context for associating the Encounter, not the EpisodeOfCare. This approach aligns with the changes in FHIR version R4, where the .context element is replaced by .encounter to support just a reference to an Encounter resource. EpisodeOfCare resource can be referenced through a new extension published in the spring of 2021 (package 2.1.1): http://nictiz.nl/fhir/StructureDefinition/extension-context-nl-core-episodeofcare.

Compatibility note: systems that went in production before this new extension was published will not be able to interpret it, unless they update for it. These systems will ignore the extension and read - as specified - the .context which is normally claimed by a reference to Encounter. Updated and newer systems may now anticipate episode associations on journal entries, diagnostic results, medication agreements and potential other encounter activities, as applicable. For more details, please see issue MM-1521.

7 Release notes

Release notes can be found on the functional design page.