MedMij:V2018.04 FHIR MedicationProcess

{{#customtitle:MedMij FHIR use case Medication Process}}

Introduction

This page describes patient's use cases, in a personal health record (PHR) context, in relation to the information standard Medication Process (MP). These use cases are based on version 9.x of this standard. Functional specification of these use cases are described in the functional design wiki page. The technical specification is described here. HL7 FHIR STU3 is used for this purpose.

The Medication Process information building blocks are adopted by 'Registratie aan de Bron' and converted to Health and Care Information models, also called ZIB's. In order to exchange medication information between systems, FHIR representations of these ZIB's are made and used in the transactions described on this page.

Use cases:

• Retrieve a medication overview
• Retrieve medication information

Actors involved

Persons		Systems		FHIR Capability Statements
Name	Description	Name	Description	Name	Description
Patient	The user of a personal healthcare enviorment.	PHR	Personal health record	CapabilityStatement: Client	Medication process client requirements
Healthcare professional	The user of a XIS	XIS	Healthcare information system	CapabilityStatement: Server	Medication process server requirements

Use case: retrieve medication overview

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 retrieve medication overview transaction is used by the PHR to retrieve a medication overview from the XIS.

Actors

Transaction group	Transaction	Actor	Role
Retrieve Medication Overview(PULL)	Retrieve medication overview request	Patient (using a PHR)	Request medication overview from the XIS
	Retrieve medication overview response	Healthcare professional (using a XIS)	Serves medication overview to the PHR

Invocations

PHR: request message

This message uses an extended operation on the RESTful API to obtain a medication overview from a XIS. This operation is used because the XIS needs to play an active role in formulating the content of the response.

Trigger Events

When the patient(PHR) wants to obtain the current medication overview, it issues a retrieve medication overview request message.

Message Semantics

The PHR executes a medication-overview operation with HTTP POST against the XIS's base endpoint as shown below.

POST [base]/$medication-overview

Expected Actions

The XIS shall process the operation to find or generate and return the current medication overview.

XIS: response message

The XIS returns a HTTP Status code appropriate to the processing of the operation as well as a Bundle of type 'collection', containing one List and one Patient resource along with other resources that represent the Medication Overview.

Trigger Events

The XIS completed processing of the retrieve medication overview request message.

Message Semantics

Based on the medication-overview operation processing results, the XIS will either return an error or success. When the XIS needs to report an error, it shall use HTTP error response codes and shall include a FHIR OperationOutcome resource with more details on the failure. If the request message is processed successfully, whether or not a Medication Overview is found or generated, the HTTP status code shall be 200.

The body of the response message shall be a Bundle resource of type "collection". The following section will elaborate on the content included.

If the XIS is sending warnings, the Bundle resource shall also contain a FHIR OperationOutcome resource that contains those warnings. The FHIR specification describes the relevant sections:

• RESTful API framework
• Operations
• Bundle resource
• OperationOutcome resource

Message content

The outcome of the medication-overview operation is the body of the medication overview request message. Successful processing of this operation should result in a Bundle recourse, containing one List and one Patient resource as entries along with all the resources that represent the current medication overview. These resources SHALL be referenced from the List resource. The clinical content of the medication overview is defined in the Medication Process specification. The functional dataset of the medication overview can be found on decor.nictiz.nl.

The content in the response message SHALL be a valid instance of the following profiles. Clicking on the link will open the formal definition on Simplifier.net.

• Bundle profile: http://nictiz.nl/fhir/StructureDefinition/Bundle-MedicationOverview
• List profile: http://nictiz.nl/fhir/StructureDefinition/MedicationOverview

The Bundle profile represents the structure of the retrieve medication overview response message. The List profile represents the actual medication overview. The List contains the medication overview metadata and references to all resources that constitute the medication overview. These resources are included in the Bundle as entries. The returned Bundle has at least one List and one Patient resource.

All returned resources to the PHR, including the Bundle and List, SHALL include their related profile canonical URL in the meta.profile element in order to show compliance. The resources in the response message SHALL be a valid instance of these profiles. In the table below, the ZIB's that constitute the clinical content of the Medication Overview and their respective profiles are listed.

Note that the medication building blocks are grouped per 'medication treatment' conform the Medication Process specification. Grouping SHALL be done by use of a 'medication treatment' identifier. This identifier shall be the same across different related medication resources that constitute a medication treatment. The zib-Medication-MedicationTreatment extenstion is added to all medication profiles and can be used for this grouping purpose.

ZIB name NL	ZIB name EN	FHIR Resource	FHIR Profile
Patient	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
Zorgverlener	HealthProfessional	Practitioner	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
Zorgaanbieder	HealthcareProvider	Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization
Medicatiegebruik	MedicationUsage	MedicationStatement	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse
Toedieningsafspraak	AdministrationAgreement	MedicationDispense	http://nictiz.nl/fhir/StructureDefinition/zib-AdministrationAgreement
Medicatieafspraak	MedicationAgreement	MedicationRequest	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
Product	Product	Medication	http://nictiz.nl/fhir/StructureDefinition/zib-Product
GebruiksInstructie	InstructionsForUse	Dosage (datatype)	http://nictiz.nl/fhir/StructureDefinition/zib-InstructionsForUse

Expected Actions

The PHR processes the results according to application-defined rules. The PHR should be robust as the response may contain medication information resources as mentioned in the former section.

Interactions, operations, search parameters

Interactions

No interactions are needed for the retrieve medication overview transaction.

Operations

The retrieve medication overview medication operation is used for this transaction. The formal definition can be found here:

• Medication Overview

Search parameters

The following search parameter type needs to be supported for this transaction.

Search parameter types:

• token

Use case: retrieve medication information

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 Retrieve Medication Information transaction is used by the PHR to retrieve medication information from the XIS. The PHR can use this transaction to retrieve the wanted information by searching on specific medication building blocks.

Actors

Transaction group	Transaction	Actor	Role
Retrieve Medication Information(PULL)	Retrieve medication information request	Patient (using a PHR)	Request medication information from the XIS
	Retrieve medication information response	Healthcare professional (using a XIS)	Serves medication information to the PHR

Invocations

PHR: request message

This message uses the HTTP GET method parameterized query to obtain medication information from a XIS. Multiple different HTTP GET request messages may be needed to retrieve all medication information.

Trigger Events

When the patient(PHR) wants to obtain medication information matching various parameters, it issues a retrieve medication information request message.

Message Semantics

The PHR executes an HTTP GET against the XIS's medication FHIR endpoints. These endpoints can be one of the following:

• MedicationRequest
• MedicationAdministration
• MedicationDispense
• MedicationStatement

The search interaction is performed by an HTTP GET conform the FHIR search specification as shown:

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

This URL is configurable by the PHR by configuring the query search parameters and search control parameters to modify the behavior of the XIS such as response format, or pagination. An example of a search for MedicationRequest resources:

GET https://vonk.test-nictiz.nl/MedicationRequest?date=gt2010-10-01

This search interaction will finds any MedicationRequest resources changed since 1-Oct 2010.

Including other resources in searchresults

The PHR may request that the XIS return resources related to the search results, in order to reduce the overall network delay of repeated retrievals of related resources. This is useful when the PHR is searching on a clinical resource, but for every such resource returned, the client will also need the subject (Patient resource) or prescriber (Practitioner resource) or medication that the clinical resource refers to. The client can use the _include parameter to indicate that the subject resources be included in the results. Example search:

GET [base]/MedicationRequest?&category=http://snomed.info/sct|16076005&_include:MedicationRequest:medication

This search interaction will find all MedicationRequest resources of the category MedicationAgreement and if present includes the referenced Medication resource.

Query Search Parameters

The PHR may supply, and the XIS SHALL be capable of processing, all query parameters listed in the table below. The XIS may choose to support additional query parameters beyond the subset listed below. Any additional query parameters supported shall be supported according to the core FHIR specification. Such additional parameters are considered out of scope for this transaction.

MP9 search parameters	Description	FHIR search parameter	FHIR resource
Identification	Search on identifier.	identifier	MedicationRequest, MedicationDispense, MedicationAdministration, MedicationStatement
Type	Search on type of medication building block (HCIM).	category * / **	MedicationRequest, MedicationAdministration, MedicationDispense, MedicationStatement
ProductCode	Search on medication code.	code	MedicationRequest, MedicationAdministration, MedicationDispense, MedicationStatement, Medication
UsePeriod	Search on medication use in the past, present or future within the specified time period.	periodofuse **	MedicationDispense, MedicationRequest
DispensePeriod	Returns all medication dispenses within the specific period.	whenhandedover	MedicationDispense

* The FHIR profiles that represent the medication building blocks contain fixed code values in the .category elements to allow searching on specific medication building blocks. FHIR resources MedicationAdministration and MedicationDispense do not contain a 'category' search parameter in the FHIR specification. Custom search parameters are provided.

** The search parameter consists of a custom created FHIR search parameter not represented in the FHIR specification.

Custom Search Parameters

The following custom search parameters are defined for this use case:

• https://simplifier.net/NictizSTU3-Zib2017/Medications-category
• https://simplifier.net/NictizSTU3-Zib2017/Medications-periodofuse

Search on fixed category code

To distinguish the ZIB medication building blocks between general medication resources, a fixed category coding has been added to the ZIB medication profiles. This fixed category code is solely used for indexing and retrieval of the ZIB building blocks. These category codings be found in the in the profiles at the .category element. The profiles are listed at the response message section below.

Example Searches

Identifier

1. https://vonk.test-nictiz.nl/MedicationRequest?identifier=http://example.nl/fhir/NamingSystem/MedicationRequest|999922448 

1. Retrieves a MedicationRequest resource with the identifier 999922448.

Type

1. https://vonk.test-nictiz.nl/MedicationRequest 
2. https://vonk.test-nictiz.nl/MedicationRequest?category=http://snomed.info/sct|16076005

1. Retrieves all MedicationRequest resources.
2. Retrieves all MedicationRequest resources that represent a ZIB MedicationAgreement.

ProductCode

1. https://vonk.test-nictiz.nl/MedicationRequest?medication.code=urn:oid:2.16.840.1.113883.2.4.4.8|13610554
2. https://vonk.test-nictiz.nl/MedicationRequest?include=Medication:medication&code=urn:oid:2.16.840.1.113883.2.4.4.8|13610554
3. https://vonk.test-nictiz.nl/MedicationRequest?category=http://snomed.info/sct|16076005&medication.code=urn:oid:2.16.840.1.113883.2.4.4.8|13610554

1. Retrieves all MedicationRequest resources that have Carbasalaatcalcium Sandoz 600 30 as medication.
2. Retrieves all MedicationRequest resources that have Carbasalaatcalcium Sandoz 600 30 as medication and includes the Medication resource in the search results.
3. Retrieves all MedicationRequest resources that represent a ZIB MedicationAgreement and have Carbasalaatcalcium Sandoz 600 30 as medication

UsePeriod

1. https://vonk.test-nictiz.nl/MedicationRequest?periodofuse=ge2010-01-01
2. https://vonk.test-nictiz.nl/MedicationDispense?periodofuse=ge2010-01-01&periodofuse=le2011-12-31
3. https://vonk.test-nictiz.nl/MedicationRequest?category=http://snomed.info/sct|16076005&periodofuse=ge2010-01-01

1. Retrieves all MedicationRequest resources that were in effect after 01-01-2010.
2. Retrieves all MedicationDispense resources that were in effect within a 2 year period.
3. Retrieves all MedicationRequest resources that represent a ZIB MedicationAgreement and were in effect after 01-01-2010.

DispensePeriod

1. https://vonk.test-nictiz.nl/MedicationDispense?whenhandedover=ge2010-01-01
2. https://vonk.test-nictiz.nl/MedicationDispense?whenhandedover=ge2010-01-01&whenhandedover=le2011-12-31
3. https://vonk.test-nictiz.nl/MedicationDispense?whenhandedover=ge2010-01-01&category=http://snomed.info/sct|373784005

1. Retrieves all MedicationDispense resources that were handed over after 01-01-2010.
2. Retrieves all MedicationDispense resources that were handed over within a 2 year period.
3. Retrieves all MedicationDispense resources that represent a ZIB Dispense and were handed over after 01-01-2010.

Expected Actions

The XIS shall process the query to discover the medication information that match the search parameters given.

XIS: response message

The XIS returns a HTTP Status code appropriate to the processing as well as a FHIR Bundle including the matching medication information.

Trigger Events

The XIS completed processing of the Retrieve medication information request message.

Message Semantics

Based on the query results, the XIS will either return an error or success. When the XIS needs to report an error, it SHALL use HTTP error response codes and SHOULD include a FHIR OperationOutcome resource with more details on the failure. If the request message is processed successfully, whether or not any medication resources are found, the HTTP status code SHALL be 200.

The response message SHALL be a Bundle resource of type "searchset" containing zero or more FHIR resources as entries. If the XIS is sending warnings, the Bundle resource SHALL also contain a FHIR OperationOutcome resource that contains those warnings. The FHIR specification describes the relevant sections:

• RESTful API framework
• Search errors
• Bundle resource
• OperationOutcome resource

Message resource content

The returned data to the PHR should conform to the medication ZIBs profiles. In the table below the medication ZIB's and their respective FHIR profiles are listed. The resources in the response message SHALL be a valid instance of these profiles. All resources SHALL include their related profile canonical URL in the meta.profile element in order to show compliance.

Note that the medication building blocks are grouped per 'medication treatment' conform the Medication Process specification. Grouping SHALL be done by use of a 'medication treatment' identifier. This identifier shall be the same across different related medication resources that constitute a medication treatment. The zib-Medication-MedicationTreatment extension is added to all medication profiles and can be used for this grouping purpose.

ZIB name NL	ZIB name EN	FHIR Resource	FHIR Profile
Patient	Patient	Patient	http://fhir.nl/fhir/StructureDefinition/nl-core-patient
Zorgverlener	HealthProfessional	Practitioner	http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
Zorgaanbieder	HealthcareProvider	Organization	http://fhir.nl/fhir/StructureDefinition/nl-core-organization
Medicatiegebruik	MedicationUsage	MedicationStatement	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse
Medicatietoediening	MedicationAdministration	MedicationAdministration	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAdministration
Toedieningsafspraak	AdministrationAgreement	MedicationDispense	http://nictiz.nl/fhir/StructureDefinition/zib-AdministrationAgreement
Medicatieafspraak	MedicationAgreement	MedicationRequest	http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
Verstrekking	Dispense	MedicationDispense	http://nictiz.nl/fhir/StructureDefinition/zib-Dispense
Verstrekkingsverzoek	MedicationDispenseRequest	MedicationRequest	http://nictiz.nl/fhir/StructureDefinition/zib-DispenseRequest
Product	Product	Medication	http://nictiz.nl/fhir/StructureDefinition/zib-Product
GebruiksInstructie	InstructionsForUse	Dosage (datatype)	http://nictiz.nl/fhir/StructureDefinition/zib-InstructionsForUse

Expected Actions

The PHR shall process the results according to application-defined rules. The PHR should be robust as the response may contain medication information resources that match the query parameters.

Interactions, operations, search parameters

Interactions

The following logical interactions are needed for the retrieve medication information transaction:

• Search

Operations

No operations are defined or needed for this transaction.

Search parameters

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

Search parameter types:

• token
• date

Search result parameters:

• _include