MedMij FHIR use case BgZ , version 2017.01

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Patient Summary (BgZ)
AfsprakenstelselFunctioneelTechnischAfspraken-Functioneel-Technisch



Introduction

Go to functional design

The Basisgegevensset Zorg (BgZ) can be seen as representation of a patient summary. The patient journey of Thomas van Beek, provides a patient's 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.

The BgZ is represents a selection of the minimal required information to provide continuity of healthcare. A total of 26 Health and Care Information models (Dutch: Zorginformatiebouwsteen or ZIB) constitute the BgZ version 1.0. The BgZ makes a subselection of the information concepts within these 26 ZIBs or restricts the ZIBs 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 26 ZIBs completely, if no existing and usable profiles were available. The profiles represent their entire respective ZIB, to make them applicable in a broader context than a patient summary or a MedMij context. An overview of the profiles can be found at the list of StructureDefinitions. This page shows how to use these profiles in the BgZ use case.

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 Verwijzing.png CapabilityStatement: Client BgZ FHIR Client requirements
Healthcare professional The user of a XIS XIS Healthcare information system Verwijzing.png CapabilityStatement: Server BgZ FHIR Server requirements

Boundaries and Relationships

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 ZIB 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 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.

List of invocations

Go to Afsprakenstelsel

This FHIR implementation guide assumes that the PHR system is able to make a connection to the XIS that contains the patient's BgZ information. 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 section 7 (Architectuur en technische specificaties) of 'Afsprakenstelsel release 1.0 version 0.3'.

Client - PHR

The PHR system can request the BgZ using individual search interactions. The search interaction searches the current resources based on some filter criteria. The interaction can be performed by an HTTP GET or command as shown:

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

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 client may also bundle the search operations in a batch. The individual requests are discussed first, followed by the batch procedure.

Individual resource requests

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

Each query contains the patient's identifier indicated with the following parameter: [patient-id]. In a MedMij PHR context, this cannot be the Patient's BSN (citizen service number). The BSN is by law not allowed to be used by other systems than those of healthcare providers. Based on infrastructure and interface specifications as described in the 'Afsprakenstelsel' a token will be used to identify the patient across the MedMij network.

# BgZ Section ZIB EN Content Example Search URL
1 Patient information Patient BSN, birthdate, gender, deceasedindicator, contact details, contact persons, and general practitioner (practitioner or organization)
GET [base]/Patient?identifier=[patient-id]&_include=Patient:general-practitioner
2 Payment details Payer Insurance information
GET [base]/Coverage?subscriber:Patient.identifier=[patient-id]&_include=Coverage:payor:Patient&_include=Coverage:payor:Organization
3 Treatment directives TreatmentDirective Known treatment directives
GET [base]/Consent?patient.identifier=[patient-id]&category=http://snomed.info/sct|11291000146105
Advance directive Known advance directives
GET [base]/Consent?patient.identifier=[patient-id]&category=http://snomed.info/sct|11341000146107
4 Contactperson Contact Primary relation/contact
see Patient
5 Functional status FunctionalOrMentalStatus Last known functional / mental status
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&category=http://snomed.info/sct|118228005,http://snomed.info/sct|364644000
6 Problems Concern All known problems for the following categories: problem, condition, diagnosis, symptom, finding, complaint, functional limitation, complication.
GET [base]/Condition?patient.identifier=[patient-id]&category:in=http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.5.1.1--20150401000000
8 Social history MaritalStatus Current marital status
see Patient
LivingSituation Current living situation
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&code=http://snomed.info/sct|365508006
DrugUse All known drug use
GET [base]/Observation?patient.identifier=[patient-id]&code=http://snomed.info/sct|228366006
AlcoholUse All known alchol use
GET [base]/Observation?patient.identifier=[patient-id]&code=http://snomed.info/sct|228273003
TobaccoUse All known tobacco use
GET [base]/Observation?patient.identifier=[patient-id]&code=http://snomed.info/sct|365980008
NutritionAdvice All known current dietary recommendations
GET [base]/NutritionOrder?patient.identifier=[patient-id]&status=active
9 Alerts Alert All known alerts
GET [base]/Flag?patient.identifier=[patient-id]
AllergyIntolerance All known information regarding allergies
GET [base]/AllergyIntolerance?patient.identifier=[patient-id]
10 Medication MedicationUse Current medication use
GET [base]/MedicationStatement?patient.identifier=[patient-id]&status=active
&category=urn:oid:2.16.840.1.113883.2.4.3.11.60.20.77.5.3|6&_include:MedicationStatement:medication
MedicationAgreement Current prescriptions
GET [base]/MedicationRequest?patient.identifier=[patient-id]&status=active
&category=http://snomed.info/sct|16076005&_include:MedicationRequest:medication
11 Medial aids MedicalAid All known medicalaids
GET [base]/DeviceUseStatement?patient.identifier=[patient-id]&_include=DeviceUseStatement:device
12 Vaccinations Vaccination All known vaccinations
GET [base]/Immunization?patient.identifier=[patient-id]&status=completed
13 Vital signs BloodPressure Last known bloodpressure
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&code=http://loinc.org|85354-9
BodyWeight Last known body weight
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&code=http://loinc.org|29463-7
BodyHeight Last known body height
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&code=http://loinc.org|8302-2,http://loinc.org|8306-3,http://loinc.org|8308-9
14 Results LaboratoryTestResult Last known laboratory results per type
GET [base]/Observation/$lastn?patient.identifier=[patient-id]&category=http://snomed.info/sct|275711006&_include=Observation:related-target&_include=Observation:specimen
15 Procedures Procedure All surgical procedures
GET [base]/Procedure?patient.identifier=[patient-id]&category=http://snomed.info/sct|365508006
16 Encounters Contact All hospital admissions (no outpatient contacts)
GET [base]/Encounter?patient.identifier=[patient-id]
&class=http://hl7.org/fhir/v3/ActCode|IMP,http://hl7.org/fhir/v3/ActCode|ACUTE,http://hl7.org/fhir/v3/ActCode|NONAC
17 Planned care PlannedCareActivity All known planned care activities
GET [base]/ProcedureRequest?patient.identifier=[patient-id]&status=active
GET [base]/ImmunizationRecommendation?patient.identifier=[patient-id]
GET [base]/MedicationDispense?patient.identifier=[patient-id]&category=http://snomed.info/sct|422037009&status=in-progress,preparation
GET [base]/DeviceRequest?patient.identifier=[patient-id]&status=active
GET [base]/Appointment?patient.identifier=[patient-id]&status=booked,pending,proposed
18 General practitioner HealthProfessional General Practitioner of the patient
see Patient

Batch request

A FHIR Bundle resource can be used to group the individual resources requests of the BgZ. If a bundle is used to query the BgZ, the bundle SHALL be of type = "batch".

A batch (type = "batch") consists of a series of entries. Each entry element SHALL contain a request element. Each entry has the details of an HTTP operation that informs the system processing the batch what to do with the entry. The bundle with type = batch is a transaction that is intended to be processed by a server as a group of actions in contrary to a bundle with type = 'transaction' where the entire set of HTTP operations is intended to be processed by a server as an atomic commit.

A batch interaction is performed by an HTTP POST command as shown:

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

The content of the post submission is a Bundle with Bundle.type = batch. Each entry carries request details (Bundle.entry.request) that provides the HTTP details of the action in order to inform the system processing the batch or what to do for the entry (note: the request is optional, but SHOULD be present). Every bundle.entry retrieves a resource using a GET method and a specified url. The XML below demonstrates a batch of requests that can be send to a server. This example can also be found here.

<Bundle xmlns="http://hl7.org/fhir">
  <id value="bundle-request-simplesummary"/> 
  <type value="batch"/> 

  <!--   Each entry is used to represent a RESTful API request
       This request retrieves a single Patient resource   -->
  <entry> 
    <request> 
      <method value="GET"/> 
      <url value="/Patient/example"/> 
    </request> 
  </entry> 
  <!--   This request will retrieve the conditions for the patient   -->
  <entry> 
    <request> 
      <method value="GET"/> 
      <url value="/Condition?patient=example"/> 
    </request> 
  </entry>
  <!--   This request will retrieve the MedicationStatements for the patient
       requested above   -->
  <entry> 
    <request> 
      <method value="GET"/> 
      <url value="/MedicationStatement?patient=example"/> 
    </request> 
  </entry>  
</Bundle> 

Example batch request

A predefined BgZ bundle batch can be found here: https://simplifier.net/NictizSTU3/BGZ-bundle-batch/~xml.

Server - XIS

Important sections of the FHIR specification for a server in this use case are the RESTful API section the search section and operation section (for the nlast operation).

Response on individual resource requests

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.

In the case of a RESTful search, these parameters are encoded in the self link in the bundle that is returned:

  <link>
    <relation value="self"/>
    <url value="http://example.org/Patient?identifier=[Patient-ID]/>
  </link>

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

Response for a batch request

For a batch the response the server SHALL return a Bundle with type set to batch-response that contains one entry for each entry in the request, in the same order, with the outcome of processing the entry. For the BgZ bundle batch, the response is a bundle of type = batch-response with multiple entries containing bundles of type = searchset that correspond to the individual search queries.

A client may use the returned Bundle to track the outcomes of processing the entry, and the identities assigned to the resources by the server. Each entry element SHALL contain a response element which details the outcome of processing the entry - the HTTP status code, and the location and ETag header values, which are used for identifying and versioning the resources. In addition, a resource may be included in the entry, as specified by the Prefer header.

Link to relevant FHIR specification: http://hl7.org/fhir/STU3/http.html#transaction-response

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]/Observation?subject=101, where "101" does not exist
  • A parameter may refer to an unknown code e.g. GET [base]/Observation?code=loinc|1234-1, where the LOINC code "1234-1" is not known to the server
  • A parameter may refer to a time that is out of scope e.g. GET [base]/Condition?onset=le1995, where the system only has data going back to 2001
  • A parameter may use an illegal or unacceptable modifier e.g. GET [base]/Condition?onset:text=1995, where the modifier cannot be processed by the server
  • A data time parameter may have incorrect format e.g. GET [base]/Condition?onset=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

Example batch response

An example of a batch response can be found here: https://simplifier.net/NictizSTU3/batch-response/~xml.

The batch-response is a bundle that contains bundles of the type = searchset in the entries. These bundles of type = searchset represent the individual queries in the bundle that is posted to the server. Please note that this example does not contain actual search results. There is no patient with the identifier '123456789' on the server. Therefore all the returned bundles are empty.

Interactions, operations, search parameters

Interactions

The following logical interactions are needed for the BgZ use case:

Operations

The following operation is needed to support 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 vitals signs. The link will provide more detailed information and examples regarding this operation.

Search parameters

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

Search parameter types:

Search result parameters:

List of StructureDefinitions

Section ZIB NL ZIB EN FHIR Resource URL Profile Reference to section
01 Patient Patient Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient Verwijzing.png Patient
02 Betaler Payer Coverage http://nictiz.nl/fhir/StructureDefinition/zib-Payer Verwijzing.png Payer
Organization http://fhir.nl/fhir/StructureDefinition/nl-core-organization Verwijzing.png HealthcareProvider
Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient Verwijzing.png Patient
03 BehandelAanwijzing TreatmentDirective Consent http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentDirective Verwijzing.png TreatmentDirective
Wilsverklaring AdvanceDirective Consent http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective Verwijzing.png AdvanceDirective
04 Contactpersoon Contact RelatedPerson http://fhir.nl/fhir/StructureDefinition/nl-core-relatedperson Verwijzing.png RelatedPerson
05 Funct. OfMentaleStatus FunctionalOrMentalStatus Observation http://nictiz.nl/fhir/StructureDefinition/zib-FunctionalOrMentalStatus Verwijzing.png FunctionalOrMentalStatus
06 OverdrachtConcern Concern Condition http://nictiz.nl/fhir/StructureDefinition/zib-Concern Verwijzing.png Concern
08 BurgerlijkeStaat MaritalStatus Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient Verwijzing.png Patient
Woonsituatie LivingSituation Observation http://nictiz.nl/fhir/StructureDefinition/zib-LivingSituation Verwijzing.png LivingSituation
DrugsGebruik DrugUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-DrugUse Verwijzing.png DrugUse
AlcoholGebruik AlcoholUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-AlcoholUse Verwijzing.png AlcoholUse
TabakGebruik TobaccoUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-TobaccoUse Verwijzing.png TobaccoUse
Voedingsadvies NutritionAdvice NutritionOrder http://nictiz.nl/fhir/StructureDefinition/zib-NutritionAdvice Verwijzing.png NutritionAdvice
Nationaliteit Nationality Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient Verwijzing.png Patient
09 Alert Alert Flag http://nictiz.nl/fhir/StructureDefinition/zib-Alert Verwijzing.png Alert
AllergieIntolerantie AllergyIntolerance AllergyIntolerance http://nictiz.nl/fhir/StructureDefinition/zib-AllergyIntolerance Verwijzing.png AllergyIntolerance
10 MedicatieGebruik MedicationUse MedicationStatement http://nictiz.nl/fhir/StructureDefinition/zib-MedicationUse Verwijzing.png MedicationUse
MedicationAgremeent MedicationRequest http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement Verwijzing.png MedicationAgreement
11 MedischHulpmiddel MedicalAid Device http://nictiz.nl/fhir/StructureDefinition/zib-MedicalAidProduct Verwijzing.png MedicalAid
DeviceUseStatement http://nictiz.nl/fhir/StructureDefinition/zib-MedicalAid
12 Vaccinatie Vaccination Immunization http://nictiz.nl/fhir/StructureDefinition/zib-Vaccination Verwijzing.png Vaccination
ImmunizationRecommendation http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
13 Bloeddruk BloodPressure Observation http://nictiz.nl/fhir/StructureDefinition/zib-BloodPressure Verwijzing.png BloodPressure
LichaamsGewicht BodyWeight Observation http://nictiz.nl/fhir/StructureDefinition/zib-BodyWeight Verwijzing.png BodyWeight
LichaamsLengte BodyHeight Observation http://nictiz.nl/fhir/StructureDefinition/zib-BodyHeight Verwijzing.png BodyHeight
14 LaboratoriumUitslag LaboratoryTestResult Observation http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation Verwijzing.png LaboratoryTestResult
DiagnosticReport http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-DiagnosticReport
Specimen http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Specimen
15 Verrichting Procedure Procedure http://nictiz.nl/fhir/StructureDefinition/zib-Procedure Verwijzing.png Procedure
16 Contact Contact Encounter http://nictiz.nl/fhir/StructureDefinition/zib-Contact Verwijzing.png Contact
17 GeplandeZorgActiviteit PlannedCareActivity ProcedureRequest http://nictiz.nl/fhir/StructureDefinition/zib-ProcedureRequest Verwijzing.png PlannedCareActivity
MedicationRequest http://nictiz.nl/fhir/StructureDefinition/zib-MedicationAgreement
ImmunizationRecommendation http://nictiz.nl/fhir/StructureDefinition/zib-VaccinationRecommendation
DeviceRequest http://nictiz.nl/fhir/StructureDefinition/zib-MedicalAidRequest
Appointment http://nictiz.nl/fhir/StructureDefinition/zib-Appointment
18 Zorgverlener HealthProfessional Practitioner http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner Verwijzing.png HealthProfessional
PractitionerRole http://fhir.nl/fhir/StructureDefinition/nl-core-practitionerrole
Zorgaanbieder HealthcareProvider Organization http://fhir.nl/fhir/StructureDefinition/nl-core-organization Verwijzing.png HealthcareProvider

Terminology, NamingSystems, Mappings

Terminology

Relevant value sets can be found here. All resources can be downloaded in a .zip in XML or JSON format. In the .zip, the value sets are stored in the directory 'value sets'.

NamingSystems

Relevant NamingSystems can be found here.

Mappings

Relevant ZIB to FHIR value set mappings can be found here. All profiles include ZIB mappings. ZIB concepts are mapped in the corresponding FHIR elements using the ZIB' concept id. The top of the StructureDefinition contains meta information regarding the ZIB mapping, such as the name and uri of the ZIB. In the StructureDefinition elements the corresponding ZIB ID is given including the mapping meta information id. This is illustrated in the following example.

<StructureDefinition>
    <id value="nl-core-patient" />
    .....
    <mapping>
        <identity value="zib-patient" />
        <uri value="https://zibs.nl/wiki/Patient(NL)" />
        <name value="Zorginformatiebouwsteen Patient" />
    </mapping>
    .....
        <element id="Patient.name">
            <path value="Patient.name" />
            <short value="NameInformation" />
            <alias value="Naamgegevens" />
            <type>
                <code value="HumanName" />
                <profile value="http://fhir.nl/fhir/StructureDefinition/nl-core-humanname" />
            </type>
            <mapping>
                <identity value="zib-patient" />
                <map value="NL-CM:0.1.6" />
            </mapping>
         </element>
     .....
</StructureDefinition>