BgZ Medisch-Specialistische Zorg Technical Implementation Guide 2.0
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1 Note on this Implementation Guide - beta status - in ontwikkeling
This alpha version of the Implementation Guide (TO) is not technically complete, but even so, it is being published in order to start obtaining feedback from the stakeholders. The current version provides an early indication of the contents being proposed.
The following items require further investigation, discussion and review amongst all stakeholders.
- Generic description of the Notified Pull communication pattern - this is being developed by Team Radar (Generic) within Nictiz at the moment and will be referred to from this TO. The intention is to avoid duplicating information at all costs.
- FHIR Notification and Workflow Task profiles - the first versions of these have been developed locally and now need to be published via Simplifier so that a reference can be made to them from this TO.
- FHIR GET (read/search) request strings - these need to be reviewed once the Referenced BgZ Resource profiles are complete.
- FHIR Referenced BgZ Resource profiles - the FO defines two new data elements that enrich the BgZ items - EersteRegistratieDatumTijd (FirstRegistrationDateTime) and MutatieDatumTijd (ContentModificationDateTime). These two fields need to be added to the corresponding BgZ FHIR resources and the mechanism for doing this is under discussion at the moment. The FHIR Provenance Resource is being considered. As soon as there is some clarity on best practices then the FHIR resource profiles will be updated and references adjusted in this TO.
The intention is to finalize agreements on these issues for the beta version of the TO. This alpha version will be updated, towards a beta version, as issues are resolved.
2 Introduction
2.1 Background
The BgZ MSZ Information Standard describes the exchange of the BgZ information between healthcare providers. The BgZ information is the minimum collection of patient data that is relevant across specialty, syndrome and profession and is important for the continuity of care. This data collection can be exchanged between care institutions. The information standard focuses on the exchange between healthcare providers of specialist medical care.
This BgZ MSZ implementation guide defines the BgZ information exchanges, in terms of use cases, based on the Zib2017 and FHIR(STU3) HL7 FHIR, STU3. HL7 CDA is no longer supported for BgZ MSZ exchange. This implementation guide assumes that the reader is familiar with this FHIR version.
Apart from this document, the guidelines as specified in general FHIR Implementation Guide apply. The guide defines methods on how to proceed with implementing FHIR STU3 and what rules apply (e.g. how to handle empty reponses etc.). In particular, the reader should take note of the Use case overarching principles and the use of FHIR packages.
2.2 About this document
This BgZ MSZ implementation guide is a technical document defining the BgZ information exchanges in terms of use cases. It should be used together with the BgZ MSZ Functional Design (FO) - see Functioneel ontwerp BgZ medisch-specialistische zorg 2.0 alpha.
The following documents also provide important background information:
- "Kwaliteitsstandaard - Uitwisseling Basisgegevensset Zorg tussen instellingen waar medisch-specialistische zorg wordt verleend" (which translates as “Exchange of BgZ between institutions where specialist medical care is provided”) [1]
- "NEN 7540:2024 BgZ-uitwisseling tussen instellingen voor medisch specialistische zorg" (which translates as “Exchange of BgZ between institutions for specialist medical care”) [2]
- "Technical Agreement - Exchanging FHIR Data using a generic Notified Pull mechanism" [3]
This document assumes reader familiarity with these references.
This implementation guide is intended to provide information for implementation/deployment needs in the Netherlands. This document is part of an evolving strategy, features will likely be added, adjusted and/or removed in future versions.
2.3 Glossary
| Term | Description |
|---|---|
| Basisgegevensset Zorg - medisch-specialistische zorg (BgZ MSZ) | Minimum collection of patient data that is relevant across specialty, clinical picture and profession and is important for the continuity of care. |
| BSN | The citizen service number (BSN) is a unique 9-digit personal number allocated to everyone registered in the Personal Records Database (BRP). Everyone who registers with the BRP is automatically given a BSN. |
| FHIR | Fast Healthcare Interoperability Resources |
| IHE | Integrating the Healthcare Enterprise |
| HCIM | Health and Care Information models (HCIM) or Zorginformatiebouwstenen (ZIB's) are used to capture functional, semantic (non-technical) agreements for the standardization of information used in the care process. |
| MedMij | MedMij is an initiative of the Dutch Patient Federation and was embraced as one of the five focus programs in 2015. The Healthcare Information Council then opted for the MedMij program. To make healthcare better, more affordable and more accessible, the Information Council is working on a sustainable information system for healthcare, in which healthcare data is exchanged securely and reliably. To this end, agreements, standards, and facilities are made, together with the participants of the Information Council. |
| VZVZ | Vereniging van Zorgaanbieders voor Zorgcommunicatie: Dutch Association for Health Providers |
| Zib | A Zib (Zorginformatiebouwstenen) defines a clinical concept in such a way that it can be used as a building block in various healthcare situations and information systems. ZIBs form the basis for the standardization of healthcare information. |
Table 2.1 Glossary
3 Boundaries and Relationships
This is the first version of the BgZ MSZ information standard in which the Notified Pull communication pattern is used to implement the "Exchange BgZ for Referral" use case. A generic description of the Notified Pull communication pattern is available (add link the Nictiz Team Radar/Generic NP description). The generic description is supplemented in this Implementation Guide by specific details defining:
- The Notification and Workflow Tasks in terms of their FHIR profiles.
- The GET request strings required to read/search for the BgZ MSZ items, defined as Input parameters in the Notification/Workflow tasks, from the Sending System by the Receiving System.
- The referenced FHIR resource profiles corresponding to the BgZ MSZ items.
4 Use Cases
Two use cases are defined in the FO as follows:
- Exchange BgZ for Referral ("Uitwisseling BgZ bij Verwijzing") from a referring (sending) healthcare provider to a receiving healthcare provider in the event of a planned referral or transfer between their two care institutions.
- Retrieval of BgZ from previous practitioner ("Opvraging BgZ bij eerdere behandelaar") by a requesting healthcare provider to his/her care institution from a different care institution.
The difference between the two use cases is mainly down to which healthcare provider takes the initiative to start the exchange of the BgZ.
4.1 Exchange BgZ for Referral
In the "Exchange BgZ for Referral" use case, the current healthcare provider (Referring (Sending) Medical Specialist) takes the initiative for a referral or transfer. In doing so, information is shared, including the BgZ (and, for example, a referral letter, additional images or reports). When the patient then attends the new care institution as a result of the referral, or transfer, the Receiving Medical Specialist can (re)use the information from the BgZ.
4.1.1 Actors
| Persons | Systems | ||
|---|---|---|---|
| Name | Description | Name | Description |
| Referring (Sending) 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 |
It is assumed that the Referring (Sending) Medical Specialist and Receiving Medical Specialist, as persons who use the BgZ sharing infrastructure, are signed on, authenticated and have authorization & consent to access the necessary (patient) information stored in the BgZ sharing infrastructure (or in other words, an authenticated healthcare professional who has an active treatment relationship with the patient). The way in which the persons achieve this state is beyond the scope of this implementation guide but is expected to be facilitated by use of the generic infrastructure.
4.1.2 Transactions
The "Exchange BgZ for Referral" use case can be implemented using two types of transactions:
- Notified Pull (preferred)
- Push
4.1.2.1 Exchange BgZ for Referral using Notified Pull Transaction
The Notified Pull communication pattern is based on the description in [3]. The Referring (Sending) Medical Specialist notifies the Receiving Medical Specialist about the referral or transfer by sending a Notification Message. The Receiving Medical Specialist can then retrieve the BgZ (at a suitable time) using the Pull Message(s) which is(are) defined as a part of the Notification Message.
This two stage approach separates the notification phase from the actual BgZ retrieval phase allowing the Receiving Medical Specialist to decide if, and when, to retrieve the BgZ.
TODO: Linked to be added to the generic description of the Notified Pull communication pattern...
The Workflow Task message is optional in the BgZ MSZ exchange and no statement about it's inclusion is made by this Implementation Guide. However, in terms of system support the following rules apply:
- The Sending System can support either a standalone Notification Task message or the combined use of the Notification Task and Workflow Task messages. If the Notified Pull is part of a workflow managed by the Sending System, then the Sending System will create a Workflow Task locally and indicate its use in the Notification Task message sent to the Receiving System.
- The Receiving System must support both the use of a standalone Notification Task message and the combined Notification / Workflow Tasks messages, depending on which option is indicated for use in the Notification Task message. When a Workflow Task is indicated then the Receiving System must retrieve the Worklow Task message from the Sending System using a separate GET operation.
The FHIR profiles describing the Notification Task message, the Workflow Task message and the retrieved BgZ item resources are defined in the FHIR Profiles section.
The FHIR search/read queries used to retrieve the BgZ item resources are defined in the FHIR Task.input Query Specification section.
NOTE: The Notified Pull, as described in [3], identifies two additional transactions based on the Notification Task:
- Notification Update
- Notification Cancellation
Both of these transactions are out of scope for this version of the Implementation Guide.
4.1.2.2 Exchange BgZ for Referral using Push Transaction
The Referring (Sending) Medical Specialist pushes the BgZ to the Receiving Medical Specialist at the time of referral or transfer and not necessarily at the time when the Receiving Medical Specialist requires the BgZ (if it is required at all).
The Push method always transfers the BgZ to the Receiving Medical Specialist even when it might not be wanted or needed.
The FHIR profiles describing the BgZ item resources are defined in the FHIR Profiles section.
Note: The Push use case can be used by systems transitioning from HL7 CDA to HL7 FHIR where the CDA based BgZ is replaced by a FHIR Composition and pushed between sending and receiving systems.
4.2 Retrieval of BgZ from previous practitioner (out of scope V2.0)
In the "Retrieval of BgZ from previous practitioner" use case, the current healthcare provider (Requesting Medical Specialist) is aware that the patient has had some previous treatment (through, for example, information provided by the patient) and takes the initiative to retrieve the details of this previous treatment from the previous care institution.
4.2.1 Actors
| Persons | Systems | ||
|---|---|---|---|
| Name | Description | Name | Description |
| Requesting Medical Specialist | Medical specialist who queries for a BgZ | EHR | Electronic health record |
It is assumed that the Requesting Medical Specialist, as person who uses the BgZ sharing infrastructure, is signed on, authenticated and has authorization & consent to access the necessary (patient) information stored in the BgZ sharing infrastructure (or in other words, an authenticated healthcare professional who has an active treatment relationship with the patient). The way in which the person achieves this state is beyond the scope of this implementation guide but is expected to be facilitated by use of the generic infrastructure.
4.2.2 Transactions
4.2.2.1 Retrieval of BgZ from previous practitioner using Pull Transaction
The Requesting Medical Specialist can retrieve the BgZ (at a suitable time) using the Pull Message.
The FHIR profiles describing the retrieved BgZ item resources are defined in the FHIR Profiles section.
The FHIR search/read queries used to retrieve the BgZ item resources are defined in the FHIR Task.input Query Specification section. The Task.input.value[x] definitions define the query search/read values to use.
5 FHIR Profiles
Note: These FHIR Profiles are under review and will be finalized by the beta version of the TO.
5.1 FHIR Notification Task
A BgZ MSZ Notification Task instance is created in the Receiving System by the Sending System issuing an HTTP POST operation to the Receiving System.
The following table identifies the location of the Notification Task FHIR profile.
| FHIR Resource | FHIR Profile |
|---|---|
| (Notification) Task | http://fhir.nl/fhir/StructureDefinition/bgz-msz-notification-task-location-to-be-added |
5.2 FHIR Workflow Task
If the Sending System supports the management of the BgZ MSZ information exchange, it will create a Workflow Task instance locally, and include details of the Workflow Task in the Notification Task exchanged with the Receiving System. The Recieving System can retrieve the Workflow Task by issuing an HTTP GET operation to the Sending System.
The following table identifies the location of the Workflow Task FHIR profile.
| FHIR Resource | FHIR Profile |
|---|---|
| (Workflow) Task | http://fhir.nl/fhir/StructureDefinition/bgz-msz-workflow-task-location-to-be-added |
5.3 FHIR Task Patient Identification
Although a patient is formally identified by their BSN in the BgZ MSZ information standard, this patient identifier is never exchanged as part of either the Notification Task or Workflow Task content. Instead, an "authorization base" token is exchanged, which only gives access by the Receiving System to specific data of a single patient managed by the Sending System.
The authorization base token is exchanged as one of the Task.input parameters in the Notification Task with a format as shown in the table below.
| FHIR Task.input.type | FHIR Task.input.value[x] as valueString |
|---|---|
codeSystem: http://fhir.nl/fhir/NamingSystem/TaskParameter code: authorization-base |
authorization base token value (encrypted) |
5.4 FHIR Task.input Query Specification
The following table provides the overview of the FHIR query (read/search) operations needed to retrieve all the BgZ MSZ items. These queries will be specified as Task.input (type and value[x]) parameters.
The Type column defines the type of query:
- Read - query for a single referenced FHIR resource instances where value[x] is a valueReference.
- Search - query for one or more FHIR resource instances where value[x] is a valueString representing the search string.
The Code (FHIR Task.input.type) column defines codedConcepts that identify the BgZ MSZ item (HCIM) to retrieve. Each codedConcept is defined in terms of the codeSystem, code and display name. NOTE: All codedConcepts/identifiers are defined by the Terminology Association in each HCIM - see ART DECOR BgZ MSZ Dataset The values are copied into this table for completeness/readability purposes.
The Value (FHIR Task.input.value[x]) column defines the query performed to retrieve the identified BgZ MSZ item.
The same Task.input parameters are applicable to the Notification Task or the Workflow Task depending on which is used to specify the BgZ MSZ retrieval operation.
NOTE to information standard reviewers: This is table defines the core BgZ MSZ Notified Pull contents and must be reviewed, accepted and adopted by all stakeholders. Please review very carefully.
| BgZ Section | HCIM | Type | Code
(FHIR Task.input.type) |
Value
(FHIR Task.input.value[x]) |
Description |
|---|---|---|---|---|---|
| 1 Patient information | Patient | Search | http://loinc.org 79191-3 "Patient demographics panel" |
GET [base]/Patient? _include=Patient:general-practitioner |
The Receiving System gets the patient identification, birth date, gender, deceased indicator, contact details, last known marital status, and general practitioner (practitioner or organization) that has been registered in the Sending System. |
| 2 Payment details | Payer | Search | http://loinc.org 48768-6 "Payment sources document" |
GET [base]/Coverage? _include=Coverage:payor:Patient& _include=Coverage:payor:Organization& _include=Coverage:payor:RelatedPerson |
The Receiving System gets the patient's insurance information that has been that has been registered in the Sending System. |
| 3 Treatment directives | Treatment Directive | Search | http://snomed.info/sct 11291000146105 "Treatment instructions" |
GET [base]/Consent? category=http://snomed.info/sct|11291000146105 |
The Receiving System gets the most recent version of all Treatment Directives that have been registered in the Sending System. |
| Advance Directive | Search | http://snomed.info/sct 11341000146107 "Living will and advance directive record" |
GET [base]/Consent? category=http://snomed.info/sct|11341000146107 |
The Receiving System gets the most recent version of all Advance Directives that have been registered in the Sending System. | |
| 4 Contact persons | Contact Person | Search | http://snomed.info/sct 70862002 "Contact person" |
see the Patient.contact element |
The Receiving System gets the most recent version of the primary partner/contact that was last registered in the Sending System. |
| 5 Functional or Mental status | Functional Or Mental Status | Search | http://loinc.org 47420-5 "Functional status assessment note" |
GET [base]/Observation/$lastn? category=http://snomed.info/sct|118228005, http://snomed.info/sct|384821006 |
The Receiving System gets, per StatusName (Observation code), the most recent version of the FunctionalOrMentalStatus that was available in the Sending System.
Specifically, not limited by, these are the last known status of the functions: mental, hearing, vision, mobility and language skills. |
| 6 Problems | Problem | Read | http://loinc.org 11450-4 "Problem list - Reported" |
GET [base]/Condition |
The Receiving System gets the most recent version of all problems that are available in the Sending System. |
| 7 Social history | Living Situation | Search | http://snomed.info/sct 365508006 "Finding of residence and accommodation circumstances" |
GET [base]/Observation/$lastn? code=http://snomed.info/sct|365508006 |
The Receiving System gets the last known living situation that is available in the Sending System. |
| Drug Use | Search | http://snomed.info/sct 228366006 "Finding relating to drug misuse behavior" |
GET [base]/Observation? code=http://snomed.info/sct|228366006 |
The Receiving System gets all Drug use that are available in the Sending System. To present the last known Drug use according to the guideline (kwaliteitsstandaard) the Receiving System should filter the data. | |
| Alcohol Use | Search | http://snomed.info/sct 228273003 "Finding relating to alcohol drinking behavior" |
GET [base]/Observation/$lastn?code=http://snomed.info/sct|228273003 |
The Receiving System gets the last known Alcohol Consumption that is available in the Sending System.
This does not have to be the Alcohol Consumption that has been updated most recently. | |
| Tobacco Use | Search | http://snomed.info/sct 365980008 "Finding of tobacco use and exposure" |
GET [base]/Observation/$lastn? code=http://snomed.info/sct|365980008 |
The Receiving System gets all Tobacco use that are available in the Sending System. To present the last known Tobacco use according to the guideline (kwaliteitsstandaard) the Receiving System should filter the data. | |
| Nutrition Advice | Search | http://snomed.info/sct 11816003 "Dietary advice" |
GET [base]/NutritionOrder |
The Receiving System gets all Nutrition Advice that is available in the Sending System. To present the last known Nutrition Advice, for each Diet Type, according to the guideline (kwaliteitsstandaard) the Receiving System should filter the data. | |
| 8 Alerts | Alert | Read | http://loinc.org 75310-3 "Health concerns document" |
GET [base]/Flag |
The Receiving System gets all Alerts available in the Sending System. |
| 9 Allergies | Allergy Intolerance | Read | http://loinc.org 48765-2 "Allergies and adverse reactions document" |
GET [base]/AllergyIntolerance |
The Receiving System gets all known allergies available in the Sending System. By default the AllergyStatus (VerificationStatus) is exchanged as "Active" unless otherwise specified differently. |
| 10 Medication | Medication Use2 | Search | http://snomed.info/sct 422979000 "Medication regimen behavior finding" |
GET [base]/MedicationStatement? category= urn:oid:2.16.840.1.113883.2.4.3.11.60.20.77.5.3|6& _include=MedicationStatement:medication |
Known medication use |
| Administration Agreement | Search | http://snomed.info/sct 422037009 "Provider medication administration instructions" |
GET [base]/MedicationDispense? category=http://snomed.info/sct|422037009& _include=MedicationDispense:medication |
Known administration agreements | |
| Medication Agreement | Search | http://snomed.info/sct 16076005 "Prescription" |
GET [base]/MedicationRequest? category=http://snomed.info/sct|16076005& _include=MedicationRequest:medication |
Known medication agreements | |
| 11 Medical aids | Medical Device | Read | http://loinc.org 46264-8 "Known medical aids" |
GET [base]/DeviceUseStatement? _include=DeviceUseStatement:device |
The Receiving System gets all medical devices available in the Sending System. |
| 12 Vaccinations | Vaccination | Read | http://loinc.org 11369-6 "History of Immunization Narrative" |
GET [base]/Immunization? status=completed |
The Receiving System gets all completed vaccinations registered in the Sending System. By default the Vaccination status is exchanged as "Completed" unless otherwise specified differently. |
| 13 Vital signs | Blood Pressure | Search | http://loinc.org 85354-9 "Blood pressure" |
GET [base]/Observation/$lastn? code=http://loinc.org|85354-9 |
The Receiving System gets the most recent version of the blood pressure that was last registered in the Sending System. |
| Body Weight | Search | http://loinc.org 29463-7 "Body weight" |
GET [base]/Observation/$lastn? code=http://loinc.org|29463-7 |
The Receiving System gets the most recent version of the body weight that was last registered in the Sending System. | |
| Body Height | Search | http://loinc.org 8302-2 "Body height" |
For last height value:
GET [base]/Observation/$lastn? code=http://loinc.org|8302-2, http://loinc.org|8306-3, http://loinc.org|8308-9 | ||
| 14 Results | Laboratory Test Result | Search | http://snomed.info/sct 15220000 "Laboratory test" |
GET [base]/Observation/$lastn?category=http://snomed.info/sct|49581000146104&_include=Observation:related-target |
The Receiving System gets the most recent version of the Laboratory Test last registered for all "Laboratory" observations, per Laboratory PanelOrBattery in the Sending System. The optional result Type of the Laboratory Result is not used for filtering. The result Type will be sent along with the data if available. |
| 15 Procedures | Procedure | Search | http://snomed.info/sct 71388002 "Procedure" |
GET [base]/Procedure?category=http://snomed.info/sct|387713003,http://snomed.info/sct|258174001 |
The Receiving System gets all operative and diagnostic procedures available in the Sending System. |
| 16 Encounters | Encounter | Search | http://loinc.org 46240-8 "History of Hospitalizations+Outpatient visits Narrative" |
GET [base]/Encounter?_include=Encounter:serviceProvider |
The Receiving System gets all contacts registered in the Sending System. |
| 17 Care Setting | Healthcare Provider | Read | http://snomed.info/sct 229774002 "Caregiver" |
GET [base]/CareTeam?status=active& _include=CareTeam:participant NOTE: .status needs to be present in the resource to get current relationships and practitioners |
The Receiving System gets the most recent version of all available caregivers registered in the Sending System. This includes at least the care providers with a current treatment relationship and, if available, care providers who are appointed in the contacts and operations that are controlled with the BgZ. |
Table 5.1 FHIR Task.input Query Specification
5.5 Referenced BgZ FHIR Resources
The profiles represent their entire respective HCIM, to make them applicable in a broader context than the exchange of BgZ or a MedMij context. An example of reuse of existing profiles is those of the patient administration resources and vital signs.
Each FHIR profile contains a 'mappings' tab that reflects the identifiers, found at release 2017 zibs/HCIMs. The reader should take note of the 'Relating FHIR profiles with their functional definitions' regarding mappings in FHIR.
Table 5.2 Referenced BgZ FHIR Resources
6 Infrastructure
6.1 Generic Infrastructure
The implementation guideline assumes that a generic infrastructure is available to provide for services like:
- Identification [NEN-7518] (of client and provider - who are you?)
- Authentication [NEN-7518] (establish that you really are who you say)
- Localization [NEN-7519] (where/what information known about the client and provider?)
- Consent [NEN-7517] (from the patient for the sharing of medical information)
- Authorization (what information are you allowed to access?)
- Addressing (digital address of provider or organization)
- Logging [NEN-7513] (audit trail - who did what, where, when and why?)
6.2 Expiration Time (exp) Claim
The "exp" (expiration time) claim identifies the expiration time on or after which the JWT MUST NOT be accepted for processing.
The value of the expiration time used in this Implementation Guide is (to be filled in).
7 References
| Reference | Document Title | Date, Version, Source |
| [1] | Kwaliteitsstandaard - Uitwisseling Basisgegevensset Zorg tussen instellingen waar medisch-specialistische zorg wordt verleend
Translates as “Exchange of BgZ between institutions where specialist medical care is provided” |
Commentaarfase februari 2023 |
| [2] | NEN 7540:2024 BgZ-uitwisseling tussen instellingen voor medisch specialistische zorg
Translates as “Exchange of BgZ between institutions for specialist medical care” |
ICS 11.020.01;35.240.80 maart 2024 |
| [3] | Technical Agreement - Exchanging FHIR Data using a generic Notified Pull mechanism | Version: 1.0.0 06-03-24 |
8 Release Notes
Changes compared to previous release.
| BITS ticket | Short description |
|---|---|
| NICTIZ-14769 | Ontwikkelen/schrijven van de TO in de wiki |
| NICTIZ-18044 | BgZ-MSZ TO - review commentaren Gabriel/Iwo bijwerken |
| NICTIZ-18045 | BgZ-MSZ TO - aanpassing ivm "Notified Pull – Hoe toe te passen in een informatiestandaard" |
| MSZ-139 | BgZ-MSZ alpha 2.0 Technical Design Feedback |
