BgZ:V1.0 BgZ 2017 Technical IG: verschil tussen versies
| Regel 44: | Regel 44: | ||
* Information Source: The person who provided the information and ensures the correctness of it... The source of information does not have to be the author of the information, who in that case is only instrumental in capturing the information. | * Information Source: The person who provided the information and ensures the correctness of it... The source of information does not have to be the author of the information, who in that case is only instrumental in capturing the information. | ||
* Author: The person who has recorded the information. | * Author: The person who has recorded the information. | ||
| + | In the context of the BgZ, when the information source is an healthcare professional (or organization), the person who entered the information (data enterer, capturer) etc. is never relevant. The only case where author can be relevant is when the patient is the source of information. In such cases, optionally, the person (healthcare professional) who provided the information may be provided as well. | ||
| − | For almost all records either | + | For almost all records either is relevant. Some listed exceptions are Patient, Contact Person, Payer. In other cases information which typically originates with the Patient, and which is recorded in the anamnesis, the preferred Basic Element to store the fact that the data is provided by the Patient is Information Source. When the information typically originates from a Healthcare Professional, such as a diagnosis, that professional is the Information Source. It is never required to provide both an Author and an Information Source when both are the same, i.e. it is not necessary to state that a diagnosis has the same doctor as Information Source AND Author, or that the Patient is Information Source AND Author of an Alcohol Use statement. Since the underlying exchange standards do not always clearly distinguish Author and Information Source (FHIR Observations have a single 'performer' which can be a Patient or a Professional) it may often not be possible to exchange both Information Source and Author. |
===Metadata table=== | ===Metadata table=== | ||
Versie van 4 dec 2021 12:16
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This version is not final yet. Do not use. |
1 Introduction
TODO
2 Actors involved
| Persons | Systems | ||
|---|---|---|---|
| Name | Description | Name | Description |
| Referring medical specialist | Medical specialist who sends a BgZ along with a referral | EHR | Electronic health record |
| Receiving medical specialist | Medical specialist receives a BgZ along with a referral | EHR | Electronic health record |
3 Use cases
4 Metadata
The functional description requires metadata for the BgZ. This chapter outlines the technical implementation of those metadata.
4.1 Document metadata
4.2 HCIM (zib) metadata
4.2.1 Basic Elements
The 2017 HCIM all have the following implicit Basic Elements which provide metadata:
4.2.1.1 IdentificationNumber
Identification is usually required for deduplication and unambiguous identification of data. Most HCIMs do not provide identification, so Problems, Procedures, Medication etc. need an IdentificationNumber. Some HCIM (such as Patient) already have an IdentificationNumber, and need no additional metadata. For some (Contact Persons) use of BSN is not permitted, and providing another non-unique id is not desirable (How could one keep that consistent over organizations?) Identification only makes sense when data has a single clear origin. In some other cases, identification is of little added value. I.e. for Body Weight, the datetime when it was recorded should suffice. To provide an additional "Body Weight id" to deduplicate Body Weight records is of little added value.
4.2.1.2 DateTime
Quite often HCIMs already have some DateTime. The relevant datetime usually is that of the event itself (say a surgery or medication administration), not of the recording of the event. For the BgZ, all relevant datetimes are already part of the HCIM. The others do not have to be provided (i.e., a Patients Contact Person carries no relevant datetime).
4.2.1.3 Subject
Subject is always implicit in the BgZ. It is always the Patient itself, except for Contact Persons and Health Professionals/Organizations, where the entire HCIM relates to the Patient and the data items therein of course pertain to the Contact Persons and Health Professionals/Organizations in question. The subject thus does not have to be separately stored, assuming the data will be stored in a Patient Record anyway, though exchange formats (certainly FHIR) may require the Patient resource to be part of exchanged data.
4.2.1.4 Author and Information Source
The basic elements state:
- Information Source: The person who provided the information and ensures the correctness of it... The source of information does not have to be the author of the information, who in that case is only instrumental in capturing the information.
- Author: The person who has recorded the information.
In the context of the BgZ, when the information source is an healthcare professional (or organization), the person who entered the information (data enterer, capturer) etc. is never relevant. The only case where author can be relevant is when the patient is the source of information. In such cases, optionally, the person (healthcare professional) who provided the information may be provided as well.
For almost all records either is relevant. Some listed exceptions are Patient, Contact Person, Payer. In other cases information which typically originates with the Patient, and which is recorded in the anamnesis, the preferred Basic Element to store the fact that the data is provided by the Patient is Information Source. When the information typically originates from a Healthcare Professional, such as a diagnosis, that professional is the Information Source. It is never required to provide both an Author and an Information Source when both are the same, i.e. it is not necessary to state that a diagnosis has the same doctor as Information Source AND Author, or that the Patient is Information Source AND Author of an Alcohol Use statement. Since the underlying exchange standards do not always clearly distinguish Author and Information Source (FHIR Observations have a single 'performer' which can be a Patient or a Professional) it may often not be possible to exchange both Information Source and Author.
4.2.2 Metadata table
Metadata are often already present in the HCIMs themselves: in that case there is no need to add them to the HCIM again. In other cases, the metadata is not relevant. The table below lists the various Basic Elements against the HCIMs.
| Required |
|
|---|---|
| Optional | This is for metadata items which are not crucial to interoperability. I.e. when a measurement already has an Author, the Information Source is not relevant. |
| Not relevant | For certain HCIMs the metadata items are not important. I.e. for the contact persons of a Patient, it is not relevant who or when recorded this. |
| Named data elements | Often the metadata items from the Basic Elements are already present in the HCIM itself. In this case these data items double as metadata, i.e. there is no need for a separate metadata item. All those metadata items are considered Required. |
| Other / textual | On other cases textual clarification is given in the table. |
| Id | Zib | HCIM | IdentificationNumber | DateTime | Author | Subject | InformationSource |
|---|---|---|---|---|---|---|---|
| NL-CM:0.1.1 | Patient | Patient | PatientIdentificationNumber | DateOfBirth | Not Relevant | Patient | Not Relevant |
| NL-CM:1.1.1 | Betaler | Payer | BankCode+AccountNumber OR IdentificationNumber+InsurantNumber | StartDateTime+EndDateTime | Not Relevant | Patient | Not Relevant |
| NL-CM:2.1.1 | BehandelAanwijzing | TreatmentDirective | Required | VerificationDate | Optional | Patient | Patient OR patient's authorized representative |
| NL-CM:7.15.1 | Wilsverklaring | AdvanceDirective | Required | LivingWillDate | Optional | Patient | Patient OR patient's authorized representative |
| NL-CM:3.1.1 | Contactpersoon | Contactperson | Not Relevant | Not Relevant | Not Relevant | Contactpersoon | Not Relevant |
| NL-CM:4.26.1 | FunctioneleOfMentaleStatus | FunctionalOrMentalStatus | Required | StatusDate | Optional | Patient | Required |
| NL-CM:5.1.1 | Probleem | Problem | Required | ProblemStartDate | Optional | Patient | Required |
| NL-CM:7.8.1 | Woonsituatie | LivingSituation | Optional | Not Relevant | Not Relevant | Patient | Optional |
| NL-CM:7.4.1 | DrugsGebruik | DrugUse | Required | StartDate | Optional | Patient | Required |
| NL-CM:7.3.1 | AlcoholGebruik | AlcoholUse | Required | StartDate | Optional | Patient | Required |
| NL-CM:7.2.1 | TabakGebruik | TobaccoUse | Required | StartDate | Optional | Patient | Required |
| NL-CM:7.11.1 | Voedingsadvies | NutritionAdvice | Required | Not Relevant | Optional | Patient | Required |
| NL-CM:8.3.1 | Alert | Alert | Required | StartDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:8.2.1 | AllergieIntolerantie | AllergyIntolerance | Required | StartDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:9.6.9580 | Medicatieafspraak | MedicationAgreement | Required | MedicationAgreementDateTime | empty OR equal to Source | Patient | Prescriber::HealthProfessional |
| NL-CM:9.8.20132 | Toedieningsafspraak | AdministrationAgreement | Required | AdministrationAgreementDateTime | empty OR equal to Source | Patient | Supplier::HealthProfessional |
| NL-CM:9.11.21338 | MedicatieGebruik | MedicationUse2 | Required | MedicationUseDateTime | empty OR equal to Source | Patient | Prescriber::HealthProfessional |
| NL-CM:10.1.1 | MedischHulpmiddel | MedicalDevice | ProductID | StartDate | empty OR equal to Source | Patient | HealthProfessional |
| NL-CM:11.1.1 | Vaccinatie | Vaccination | ProductCode+VaccinationDate | VaccinationDate | empty OR equal to Source | Patient | Administrator::Healthprofessional |
| NL-CM:12.4.1 | Bloeddruk | BloodPressure | BloodPressureDateTime | BloodPressureDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:12.1.1 | Lichaamsgewicht | BodyWeight | WeightDateTime | WeightDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:12.2.1 | Lichaamslengte | BodyHeight | HeightValue OR HeightDateTime | HeightDateTime | empty OR equal to Source | Patient | Required |
| NL-CM:14.1.1 | Verrichting | Procedure | Required | ProcedureStartDate | empty OR equal to Source | Patient | Performer::HealthProfessional |
| NL-CM:15.1.1 | Contact | Encounter | ContactType + StartDateTime | StartDateTime | empty OR equal to Source | Patient | ContactWith::HealthProfessional |
| NL-CM:17.1.1 | Zorgverlener | HealthProfessional | HealthProfessionalIdentificationNumber | Not Relevant | Not Relevant | HealthProfessional | Not Relevant |
4.3 Persistent identifiers
5 Reconciliation
Metadata provides the opportunity for reconciliation: combining patient data from multiple sources in a consistent and integrated way. This may involve:
- receiving information, such as a BgZ, from another source and integrating that in one's own EHR;
- retrieving information from multiple sources, and showing that in a consistent and unambiguous way.
Reconciliation involves the following.
- De-duplication: data item X may be available from multiple sources, and should only be shown once. De-duplication is possible through consistent identifiers across data custodians.
- Semantic interpretation: data items from multiple sources should be classified in a consistent way, which is interoperable across sources. Semantic interoperability is possible through the use of consistent classification and terminologies. The HCIMs themselves, along with "Eenheid van Taal" (Unity of Language) terminology services already provide the necessary level of semantic interoperability.
- Provenance: it should be clear which data originates where, and the original source should be traceable and (where still possible) approachable. Provenance is achieved through authorship and information source.
- Attribution: patient data is a statement: usually a fact that something is the matter about something or someone at some point in time. Subject and date/time information allow the data item to be related to the real world.
5.1 Provenance
Every data item is a statement, an assertion of a fact, recorded by someone somewhere. This original source should be retained when integrating data from multiple sources. The source can be:
- An individual as author of the statement. Examples:
- a health professional makes a diagnosis
- a patient reports alcohol and tobacco use
- An organization as author of the statement. Examples:
- a lab reports certain chemical or biological measurements on a specimen
- An information source:
6 FHIR profiles
The FHIR profiles defined for MedMij are also used for the BgZ.
7 CDA templates
The following CDA templates are used for the BgZ.