Introduction

This page describes how patient can manage their health care related appointments in a MedMij context using the HL7 FHIR Standard. Initially this guide will contain information on how to request existing appointment information. Guidance on how to create, update, or cancel appointments will be available here as well in a later stage. The functional requirements for this use case can be found here.

Use case: retrieve appointments

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.

Introduction

The goal of this use case is to give patients an overview of their appointments with all health care providers. The appointment information that is shared with the patient will contain start and end date/time, location, type of appointment, patient instructions, health care professionals present. Below is described how a PHR can retrieve this information and how a XIS should make this information available.

Actors

Actor	Role
Patient (using a PHR)	Request appointments from the XIS
Healthcare professional (using a XIS)	Serves appointments to the PHR

Invocations

Client - PHR

Search for appointments

The PHR system can request the appointments using individual search interactions. The search interaction searches for appointments based on start date/time. The interaction can be performed by an HTTP GET as shown:

GET [base]/Appointment/?date=[date]

for more information on how to query on dates using FHIR see the FHIR search specification

examples:

retrieve appointments from 01-01-2018 onwards:

GET [base]/Appointment/?date=gt2017-12-31

retrieve appointments from 01-01-2018 until 01-03-2018

GET [base]/Appointment/?date=ge2018-01-01&date=lt2018-03-01

Server - XIS

Important sections of the FHIR specification for a server in this use case are the RESTful API section the search section.

Response on search request

If the search succeeds, the server SHALL return a 200 OK HTTP status code and the return 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 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

Handling errors

If the search fails (cannot be executed, not that there is no matches), the return value is a status code 4xx or 5xx with an OperationOutcome. A 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. When the search fails, a server SHOULD return an OperationOutcome detailing the cause of the failure. Note: An empty search result is not a failure.

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

A parameter may refer to a non-existent resource e.g. GET [base]/Appointment?patient=101, where "101" does not exist
A parameter may refer to an unknown code e.g. GET [base]/Appointment?appointment-type=83280, where the 83280 is not known to the server
A parameter may refer to a time that is out of scope e.g. GET [base]/Appointment?date=le1995, where the system only has data going back to 2001
A data time parameter may have incorrect format e.g. GET [base]/Appointment?date=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.

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

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

Interactions, operations, search parameters

Interactions

The following FHIR interactions are needed to retrieve appointment information:

Search

Operations

No operations are defined or needed for this transaction.

Search parameters

Name	Type	Description	Expression
date	date	Appointment date/time.	Appointment.start

Profiles

Name NL	Name EN	FHIR Resource	URL profile	Reference to section
Patient	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient	Patient
Zorgverlener	HealthProfessional	Practitioner	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner	HealthProfessional
Zorgaanbieder	HealthcareProvider	Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization	HealthcareProvider
Afspraak	Appointment	Appointment	http://nictiz.nl/fhir/StructureDefinition/eAfspraken-Appointment	Appointment

Examples

Use case: book an appointment

NOTE: THIS USE CASE IS NOT YET SUPPORTED BY THE MEDMIJ "AFSPRAKENSTELSEL": CHANGES TO THE AFSPRAKENSTELSEL CAN INFLUENCE THE SPECIFICATION OF THIS USE CASE

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.

Introduction

The goal of this use case is to allow patients to book an appointment at a certain selected health care provider. Below is described how a PHR can send an appointment request and how a XIS should handle this.

Actors

Actor	Role
Patient (using a PHR)	Book appointment
Healthcare professional (using a XIS)	Handles appointment request

Invocations

Client - PHR

Search for available slots

The PHR system can request available slots using the $find operation with optional input parameters on the Slot endpoint. This operation is a request for the XIS to calculate available slots, and provide a Bundle resources with available slots as return. The operation can be performed by an HTTP POST as shown:

POST [base]/Slot/$find

The optional input parameters can be put in the request body using the Parameters resource.

example body

{
  "resourceType": "Parameters",
  "parameter": [
    {
      "name": "start",
      "valueDateTime" : "2017-07-15T20:00:00Z"
    },
    {
      "name": "end",
        "valueDateTime" : "2017-07-17T20:00:00Z"
    }
]
}

A Bundle containing the available Slot resources and an optional OperationOutcome resource can be expected as return.

For more information on how operations work using FHIR see the FHIR search specification

Book appointment

After fetching open Slots, an Appointment resource is created by the Client Application and is exchanged with the EHR. This Appointment will be the parameter for the $book operation. The operation can be performed by an HTTP POST as shown:

POST [base]/Appointment/$book

The proposed Appointment has to be put in the request body using the Parameters resource.

{
   "resourceType": "Parameters",
   "parameter": [
      {
         "name": "appointment",
         "resource": {
            "resourceType": "Appointment",
            --snip--
         }
      },
   ]
}

A Bundle containing an required Appointment resource with status "booked" or "cancelled" and an optional OperationOutcome resource can be expected as return.

Server - XIS

Important sections of the FHIR specification for a server in this use case are the RESTful API section and the operations section.

Serve available slots

A Client can fetch available slots using the $find operation. (See client section above for details). A server is expected to answer this operation with a Bundle containing the available Slots based on the clients input parameters, and/or an optional OperationOutcome resource.

Handle appointment booking request

A Client can propose an appointment to be booked using the $book operation. (See client section above for details). A server is expected to answer this operation with a Bundle containing the the proposed appointment with either a "booked" or "cancelled" status based on the XIS's internal logic. The server can also send an optional OperationOutcome resource, containing a "success" or "error" explaining the result.

Response on operation request

If an operation succeeds, an HTTP Status success code is returned. This will usually be a 2xx code, though it may also be a 303 See Other. Other kinds of 3xx codes should be understood to indicate that the operation did not proceed, and the client will need to re-issue the operation if it can perform the redirection (e.g. may get redirected to an authentication step). User agents should note that servers may issue redirects, etc. to authenticate the client in response to an operation request. An HTTP status code of 4xx or 5xx indicates an error, and an OperationOutcome SHOULD be returned with details.

In general, an operation response uses the Parameters format whether there is only one or there are multiple named out parameters. However, the defined $find operation only has one out parameters named "return". This means the parameters doesn't have to be used and the response is simply the resource itself. Which in this case is a Bundle resource of type "search-response", containing the requested resources.

The resources that are returned by the operation may be retained and made available in the resource repository on the operation server. In that case, the server will provide the identity of the resource in the returned resources. When resources that are not persisted are returned in the response, they will have no id property.

Link to the relevant FHIR specification: http://hl7.org/fhir/stu3/operations.html

Interactions, operations, search parameters

Interactions

The following FHIR interactions are needed to retrieve avaialable slots information:

Operations

Operations

$find (Find available Slots): http://nictiz.nl/fhir/OperationDefinition/eafspraken-slot-find

$book (Book Appointment): http://nictiz.nl/fhir/OperationDefinition/eAfspraken-appointment-books

Profiles

Name NL	Name EN	FHIR Resource	URL profile	Reference to section
Patient	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient	Patient
Zorgverlener	HealthProfessional	Practitioner	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner	HealthProfessional
Zorgaanbieder	HealthcareProvider	Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization	HealthcareProvider
Afspraak	Appointment	Appointment	http://nictiz.nl/fhir/StructureDefinition/eAfspraken-Appointment	Appointment
Slot	Slot	Slot	http://nictiz.nl/fhir/StructureDefinition/eAfspraken-Slot	Slot

Examples

MedMij FHIR Implementation Guide - eAfspraak

Inhoud

Introduction

Use case: retrieve appointments

Introduction

Actors

Invocations

Client - PHR

Search for appointments

Server - XIS

Response on search request

Handling errors

Interactions, operations, search parameters

Interactions

Operations

Search parameters

Profiles

Examples

Use case: book an appointment

Introduction

Actors

Invocations

Client - PHR

Search for available slots

Book appointment

Server - XIS

Serve available slots

Handle appointment booking request

Response on operation request

Interactions, operations, search parameters

Interactions

Operations

Profiles

Examples

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