MedMij FHIR Implementation Guide: BgZ

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Patient Summary (BgZ)

1 Introduction

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The program ‘Registratie aan de bron’ (Clinical documentation at the point of care) has defined Health and Care Information models (HCIMs (English) or zibs (Dutch)) for The Netherlands. Next to these HCIMs, the program ‘Registratie aan de bron’ also made a selection of these HCIMs into the so-called ‘Basisgegevensset Zorg’ (Common Clinical Dataset, a Dutch version of a ‘patient summary’, further referred to as ‘BgZ’). The BgZ serves as a minimal healthcare dataset that is always appropriate for caregivers in order to provide continuity of care for a patient and can be seen as a representation of a patient summary.

A subselection of the published HCIMs release 2017 constitute the BgZ 2017. The BgZ makes a subselection of the information concepts within the HCIMs or restricts the HCIMs to a certain category. For example, only include the general practitioner of the patient or only the last known value of 'X'. MedMij created FHIR profiles that represent these HCIMs completely if no existing and usable profiles were available. The profiles represent their entire respective HCIM, to make them applicable in a broader context than a patient summary or even the MedMij context. An overview of the profiles can be found at the list of profiles.

The patient journey of Thomas van Beek, provides a patients context for exchanging a patient summary from a healthcare provider's system (XIS) to a personal health record (PHR). MedMij created a functional design of the BgZ use case. This use case consists of enabling a patient to view his own BgZ in a PHR. This page will elaborate further on the HL7 FHIR details needed to exchange the BgZ information using FHIR.

Note: This implementation guide builds on the general guidelines described in the use case overarching principles.

2 Actors involved

Actors Systems FHIR Capability Statements
Name Description Name Description Name Description
Patient The user of a personal healthcare environment. PHR Personal health record Verwijzing.png CapabilityStatement: Client FHIR Client requirements
Healthcare professional The user of a XIS XIS Healthcare information system Verwijzing.png CapabilityStatement: Server FHIR Server requirements

3 Boundaries and Relationships

The BgZ 2017 v1.1 use case follows the BgZ v1.0 use case. The difference between the two is the underlying HCIMs, which have been upgraded from release 2015 to release 2017. The changes are documented in a release notes document.

The BgZ use case has similarities and differences with other use cases such as Medication Process, Vital Signs and Lab Results. These use cases use the same HCIM based FHIR profiles for exchanging information. The BgZ use case covers practically all profiles included in the other use cases. However, the BgZ differs in the scope of the actual health information content that should be exchanged. For example, the BgZ conveys only the last known lab result of each type while the Lab Results use case may cover all known information.

4 Use Case: Retrieve BGZ information

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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.

4.1 PHR: request message

The PHR system requests the BgZ using individual search interactions. The BgZ consists of multiple FHIR resources with certain constraints. To obtain the patient's BgZ, the client can use multiple individual search operations based on specified search queries. The interactions are performed by an HTTP GET as shown:

GET [base]/[type]{?[parameters]}

The table below shows in the first four columns the BgZ sections, the HCIMs that constitute those sections and the specific content of the BgZ. The last column shows the FHIR search queries to obtain the BgZ information. These queries and expected responses are based on profiles listed in this section.

# BgZ Section HCIM EN Content Search URL[1]
1 Patient information Patient Identification, birth date, gender, deceased indicator, contact details, last known marital status, and general practitioner (practitioner or organization)
GET [base]/Patient?_include=Patient:general-practitioner
2 Payment details Payer Insurance information
GET [base]/Coverage?_include=Coverage:payor:Patient&_include=Coverage:payor:Organization
3 Treatment directives TreatmentDirective Known treatment directives
GET [base]/Consent?category=|11291000146105
AdvanceDirective Known advance directives
GET [base]/Consent?category=|11341000146107
4 Contact persons ContactPerson First relation/contact
see Patient
5 Functional status FunctionalOrMentalStatus Last known functional / mental status
GET [base]/Observation/$lastn?category=|118228005,|384821006
6 Problems Concern All known problems
GET [base]/Condition
7 Social history LivingSituation Current living situation
GET [base]/Observation/$lastn?code=|365508006
DrugUse All known drug use
GET [base]/Observation?code=|228366006
AlcoholUse All known alcohol use
GET [base]/Observation?code=|228273003
TobaccoUse All known tobacco use
GET [base]/Observation?code=|365980008
NutritionAdvice All known dietary recommendations
GET [base]/NutritionOrder
8 Alerts Alert All known alerts
GET [base]/Flag
9 Allergies AllergyIntolerance All known information regarding allergies
GET [base]/AllergyIntolerance
10 Medication MedicationUse Known medication use
GET [base]/MedicationStatement?category=urn:oid:2.16.840.1.113883.|6&_include=MedicationStatement:medication
MedicationAgreement Known medication agreements
GET [base]/MedicationRequest?category=|16076005&_include=MedicationRequest:medication
AdministrationAgreement Known administration agreements
GET [base]/MedicationDispense?category=|422037009&_include=MedicationDispense:medication
11 Medical aids MedicalDevice Known medical aids
GET [base]/DeviceUseStatement?_include=DeviceUseStatement:device
12 Vaccinations Vaccination Known vaccinations
GET [base]/Immunization?status=completed
13 Vital signs BloodPressure Last known blood pressure
GET [base]/Observation/$lastn?code=|85354-9
BodyWeight Last known body weight
GET [base]/Observation/$lastn?code=|29463-7
BodyHeight Last known body height
GET [base]/Observation/$lastn?code=|8302-2,|8306-3,|8308-9
14 Results LaboratoryTestResult Last known laboratory results per type
GET [base]/Observation/$lastn?category=|275711006&_include=Observation:related-target&_include=Observation:specimen
15 Procedures Procedure Known surgical procedures
GET [base]/Procedure?category=|387713003
16 Encounters Contact Known hospital admissions (no outpatient contacts)
GET [base]/Encounter?class=|IMP,|ACUTE,|NONAC
17 Planned care PlannedCareActivityForTransfer Known planned care activities
GET [base]/ProcedureRequest?status=active
GET [base]/ImmunizationRecommendation
GET [base]/MedicationDispense?category=|422037009&status=in-progress,preparation&_include=MedicationDispense:medication
GET [base]/DeviceRequest?status=active&_include=DeviceRequest:device
GET [base]/Appointment?status=booked,pending,proposed
18 General practitioner HealthProfessional General Practitioner of the patient
see Patient
  1. See Search URLs and search parameters for the interpretation of these search URLs

4.2 XIS: response message

The returned data to the PHR should conform to the profiles listed in #List_of_profiles.

4.3 The $lastn operation

The following operation is needed for this use case.

The $lastn query meets the common need for searching for the most recent or last n=number of observations for a subject. For example, retrieving the last 5 temperatures for a patient to view trends or fetching the most recent laboratory results or vital signs. The link will provide more detailed information and examples regarding this operation.

The $lastn FHIR STU3 specification is vague regarding the sorting mechanism of $lastn. In FHIR R4 however, this has been clarified and can be read as follows: when using $lastn, the effective[x] element is used for sorting of Observations, sorted from most recent to the oldest.

5 List of profiles

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.

Section Zib NL HCIM EN FHIR Resource FHIR Profile
1 Patient Patient Patient
BurgerlijkeStaat MaritalStatus Patient.maritalStatus
2 Betaler Payer Coverage
3 BehandelAanwijzing TreatmentDirective Consent
Wilsverklaring AdvanceDirective Consent
4 Contactpersoon ContactPerson
5 FunctioneleOfMentaleStatus FunctionalOrMentalStatus Observation
6 Probleem Problem Condition
7 Woonsituatie LivingSituation Observation
DrugsGebruik DrugUse Observation
AlcoholGebruik AlcoholUse Observation
TabakGebruik TobaccoUse Observation
Voedingsadvies NutritionAdvice NutritionOrder
8 Alert Alert Flag
9 AllergieIntolerantie AllergyIntolerance AllergyIntolerance
10 MedicatieGebruik2 MedicationUse2 MedicationStatement
Medicatieafspraak MedicationAgreement MedicationRequest
Toedieningsafspraak AdministrationAgreement MedicationDispense
11 MedischHulpmiddel MedicalDevice Device
12 Vaccinatie Vaccination Immunization
13 Bloeddruk BloodPressure Observation
LichaamsGewicht BodyWeight Observation
LichaamsLengte BodyHeight Observation
14 LaboratoriumUitslag LaboratoryTestResult Observation
15 Verrichting Procedure Procedure
16 Contact Encounter Encounter
17 OverdrachtGeplandeZorgActiviteit PlannedCareActivityForTransfer ProcedureRequest *
MedicationDispense **
ImmunizationRecommendation *
DeviceRequest *
Appointment *
18 Zorgverlener HealthProfessional Practitioner
Zorgaanbieder HealthcareProvider Organization

6 Release notes

Release notes can be found on the functional design page.

7 Support

For questions and change requests regarding the information on this page, please create a ticket in BITS