{{#customtitle:MedMij FHIR Implementation Guide: Questionnaire and Questionnaire Response (Vragenlijsten)}} MedMij:Vdraft Issuebox FHIR IG

1 Introduction

This page describes the exchange of questionnaires and questionnaire responses within MedMij. A questionnaire is an organized collection of questions intended to solicit information from patients, providers or other individuals involved in the healthcare domain. These questionnaires may take the form of a straightforward flat list of questions, but they can consist of hierarchically organized groups and sub-groups. Likewise, there can be a wide range of question types, varying from simple fill-out forms to multiple choice questions and scales.

These questionnaires are captured using the FHIR Questionnaire resource, which defines the questions to be asked, their ordering and grouping, instructional text and the constraints on the answers. The results of a Questionnaire can be communicated using the QuestionnaireResponse resource. To support the logistics of assigning and answering a questionnaire, a Task resource is used.

This information standard is inspired by the international Structured Data Capture (SDC) implementation guide and tries to follow it where possible. However, the first version of this information standard is more restricted than SDC; specifically, the possibility for a XIS to pre-populate the questionnaire response is omitted in this first version. Also, contrary to most other use cases for MedMij, no specific HCIM models have been identified for prescribing and answering questionnaires.

Note: this page is part of the MedMij FHIR Implementation Guide and is a technical representation of the functional design published on this wiki page.

2 Actors involved

Table 1 shows the relevant actors, systems and FHIR Capability Statements in MedMij context. The Capability Statements demonstrate the minimum conformance requirements for the described use cases. The role that covers the provision of a Questionnaire MAY be integrated in the XIS or MAY be supported by a separate questionnaire repository. That means the role of XIS in table 1 MAY also be supported by a questionnaire repository.

Note: in the (TODO: waar is dit vastgelegd?), only the PGO can initiate communication with the XIS, not the other way around. Therefore, the healthcare provider needs to inform the patient about the questionnaire offline. The PGO should provide an interface to the user to manually check a specific healthcare provider for questionnaire tasks. (TODO: op een meer prominente plek uitleggen?).

(TODO: de meeste andere standaarden hebben alleen een tabel met actors, niet met transactions) (TODO: de andere standaarden hebben een capabilitystatement per actor, niet per actor/resource. Dat zouden er bij ons drie worden: client, server en repository)

Actors		Systems		FHIR Capability Statements
Name	Description	Name	Description	Name	Description
Patient	The user of a personal healthcare environment retrieves a QuestionnaireReferenceTask	PHR	Personal health record	CapabilityStatement: Client gets Task	FHIR Client requirements
Patient	The user of a personal healthcare environment retrieves a Questionnaire and updates the QuestionnaireReferenceTask.	PHR	Personal health record	CapabilityStatement: Client gets Questionnaire (TODO: determine if search is necessary in CS. Task uses reference, so only read is required?)	FHIR Client requirements
Patient	The user of a personal healthcare environment provides a QuestionnaireResponsean and updates the QuestionnaireReferenceTask.	PHR	Personal health record	CapabilityStatement: Client provides QuestionnaireResponse	FHIR Client requirements
Healthcare professional	The user of a XIS provides a QuestionnaireReferenceTask.	XIS	Healthcare information system	CapabilityStatement: Server provides Task	FHIR Server requirements
Healthcare provider / Questionnaire repository	The healthcare provider provides a Questionnaire.	XIS	Healthcare information system	CapabilityStatement: Server provides Questionnaire (TODO: determine if search is necessary in CS. Task uses reference, so only read is required?)	FHIR Server requirements
Healthcare provider	The healthcare provider accepts an update the QuestionnaireReferenceTask	XIS	Healthcare information system	CapabilityStatement: Server accepts update to Task (TODO: support for update)	FHIR Server requirements
Healthcare provider	The healthcare information system accepts creation of a QuestionnaireResponse and an updates the QuestionnaireReferenceTask.	XIS	Healthcare information system	CapabilityStatement: Server accepts QuestionnaireResponse	FHIR Server requirements

Table 1. Actors, systems and FHIR Capability Statements

3 Boundaries and Relationships

The MedMij use case for questionnaires overlaps partially with SDC use cases. Where possible, the SDC profiles are re-used. However, the current use case is more restricted than the SDC use cases. Furthermore, the MedMij derived profiles reference HCIM based profiles for common resources like Patient, Practitioner, PractitionerRole and Organization.

The QuestionnaireResponse.author tells who the person is that provided the answers. For the current MedMij use case it may be a patient. The QuestionnaireResponse.subject tells who the answers apply to. For the current MedMij use case it may be a patient, organization or practitioner.

4 Use case: retrieve Questionnaire

4.1 List of invocations

The order of invocations follows the Functional Design (TODO: link). At first the Questionnaire is assigned to the patient by a QuestionnaireReferenceTask. The PHR extracts the reference to the Questionnaire and retrieves it from the XIS or from an external Questionnaire repository.

4.1.1 Client gets Questionnaire reference - PHR

Using a search operation, the PHR provides a Task containing a reference to the patient questionnaire from the XIS. The Task SHALL conform to the MedMij QuestionnaireReferenceTask profile. A search interaction can be performed by an HTTP GET or command as shown:

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

(TODO: moet de task hier al geüpdatet worden?)

4.1.2 Client gets Questionnaire - PHR

The PHR system retrieves the Questionnaire assigned to patient using a read operation. The Questionnaire SHALL conform to the MedMij questionnaire profile. A read interaction MAY be based on the reference for the Questionnaire found in the Task.focus element (but MAY also be obtained through other means outside the scope of this specification. TODO: huh?)

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

Upon retrieving the Questionnaire resource, the PHR checks if it is able to present a form that completely covers all the questions and structure and updates the task accordingly, using an update operation. If the Questionnaire can be processed, Task.status SHALL be set to (TODO). If the Questionnaire cannot be processed, Task.status SHALL be set to (TODO) and (TODO: andere velden van de task):

PUT [base]/Task/id{?[parameters]{&_format=[mime-type]}}

4.2 Client renders questionnaire form - PHR

The PHR should present the questions defined in the retrieved Questionnaire resource to the user, in accordance with their type, overall structure of the questionnaire, and restrictions on the answers. MedMij defines the following minimal subset of Questionnaire item types that a PHR MUST support:

Group
Display
Boolean
Decimal
Integer
Date / dateTime / time
String
Choice / open-choice
Quantity

The following elements of the Questionnaire.item element MUST be supported:

Questionnaire.item.enableWhen
Questionnaire.item.required
Questionnaire.item.options

In addition, the extensions minValue and maxValue MUST be supported.

A PHR MAY support other Questionnaire item types as well. However, if a PHR is unable to process any one part in the Questionnaire, it MUST reject the Questionnaire altogether. See (TODO).

Note: for known questionnaires, a PHR may choose to use hardcoded instead of generated forms. However, PHRs implementing this information standard should always be able to generate a form for the minimal Questionnaire subset defined above. Also note that a known questionnaire can only be recognized by its reference in the Task; currently, no coding system exists to identify known questionnaires.

5 Use case: send QuestionnaireResponse

5.1 List of invocations

This FHIR implementation guide assumes that the PHR system is able to make a connection to the XIS to send QuestionnaireResponse. 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'.

5.1.1 Client provides QuestionnaireResponse - PHR

The answers to the questions in the Questionnaire are captured using an instance of the QuestionnaireResponse resource. Upon completion by the user, the PHR system sends this QuestionnaireResponse to the XIS and closes the original Task on the XIS. This is done by POSTing both resources using a FHIR transaction, according to the following structure (where ORIGINAL_ID is the original Task.id from the Task retrieved from the server): (TODO: of moeten het twee aparte operaties zijn?)

<Bundle xmlns="http://hl7.org/fhir">
    <type value="transaction"/>
    <entry>
        <resource>
            <Task>
                <id value="ORIGINAL_ID"/>
                <meta>
                    <profile value="..."/>
                </meta>
                <status value="completed"/>
                <output>
                    <type>
                        <text value="QuestionnaireResponse"/>
                    </type>
                    ...
                    <valueReference>
                        <reference value="urn:uuid:e607a55c-194d-447a-8cc7-7ab90e3660c3"/>
                        <display value="Response to questionnaire XXX">
                    </valueReference>
                </output>
            </Task>
        </resource>
        <request>
            <method value="PUT"/>
            <url value="Task/ORIGINAL_ID"/>
        </request>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:e607a55c-194d-447a-8cc7-7ab90e3660c3"/>
        <resource>
            <QuestionnaireResponse>
                <meta>
                    <profile value="..."/>
                </meta>
                ...
            </QuestionnaireResponse>
        </resource>
    </entry>
    <request>
        <method value="POST"/>
        <url value="QuestionnaireResponse"/>
    </request>
</Bundle>

The QuestionnaireResponse SHALL conform to the MedMij questionnaire response profile.

This interaction is performed using an HTTP POST:

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

If the server is unable to process either of the resources, it shall not process any one of them and return an HTTP 400 or HTTP 500 type response. If the server is able to process both resources, it SHALL return a HTTP 200 OK status code and SHALL also return a Bundle of type 'transaction-response', that contains one entry for each entry in the request, in the same order, with the outcome of processing the entry. (TODO: for real ... dit hoeven we toch niet allemaal over te pennen van de FHIR spec?)

Note: updating the QuestionnaireResponse is not supported in the use case.

6 Handling errors

(TODO: kan dit er niet gewoon uit?) 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.
A parameter may refer to an unknown code
A parameter may refer to a time that is out of scope
A parameter may use an illegal or unacceptable modifier
A date/time parameter may have incorrect format
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

7 Interactions, operations, search parameters

7.1 Interactions

The following logical interactions are needed for the use case of Questionnaire and Questionnaire Response:

Search -- Task
Update -- Task
Read -- Questionnaire
Create -- QuestionnaireResponse

7.2 Operations

The following operations have been specified for use in SDC. The MedMij use case has no identified requirement for these operations. This specification therefor does not define that system roles implement them.

7.3 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

7.4 List of StructureDefinitions

The unique FHIR profiles based on HCIM applicable in a broader context than the exchange of Questionnaire and Questionnaire Response.

FHIR Profile	FHIR Resource	HCIM NL / Concept
http://fhir.nl/fhir/StructureDefinition/nl-core-patient	Patient	Patient
http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner	Practitioner	Zorgverlener
http://fhir.nl/fhir/StructureDefinition/nl-core-practitionerrole	PractitionerRole	Zorgverlenerrol
http://fhir.nl/fhir/StructureDefinition/nl-core-organization	Organization	Zorgaanbieder
http://nictiz.nl/fhir/StructureDefinition/nl-core-questionnaire	Questionnaire	Questionnaire
http://nictiz.nl/fhir/StructureDefinition/nl-core-questionnaireresponse	QuestionnaireResponse	Questionnaire Response
http://nictiz.nl/fhir/StructureDefinition/QuestionnaireReferenceTask	Task	Questionnaire Reference

Zandbak/MVPTO

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