MedMij FHIR Implementation Guide basic GGZ data 1.1.5

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GGZ
AfsprakenstelselFunctioneelTechnischAfspraken-Functioneel-Technisch

Introduction

The page describes the FHIR requirements for exchanging GGZ information between the patients and healthcare providers in the context of MedMij. The overarching FHIR requirements, described in the technical IG guide homepage, are applicable here.

Actors involved

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

Boundaries and Relationships

The GGZ use case has similarities and differences with other use cases such as the BgZ, Medication Process, Vital Signs, GP Patient Data and Lab Results. These use cases use much of the same HCIM based FHIR profiles for exchanging information. Wherever possible every attempt is made to re-use the profiles as used in the BgZ. The GGZ use case also has unique profiles compared to the aforementioned use cases. In addition, it has a CareTeam profile without an underlying HCIM. A second thing to note is that while the selection criteria of certain sections like procedure do not match with the BgZ or other use cases, this does not affect the profiles in use. For example, it is irrelevant for the response profile for procedures if you request ' surgical procedures' or 'every procedure'.

Use case: retrieve GGZ 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 patients GGZ 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 the 'Afsprakenstelsel'.

Client - PHR

The PHR system requests the patient's GGZ information using individual search interactions over multiple FHIR resources. The client can use multiple individual search operations based on specified search queries. A search interaction can be performed by an HTTP GET or command as shown:

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

The table below shows in the first three columns the HCIM name in Dutch, in English and what HCIM content is requested. The last column shows the FHIR search queries to retrieve this information. The queries are based on the functional GGZ information exchange requirements, which are stated in the functional overview and shown in detail in this table. The queries, and more profoundly the response messages follow the profiles listed in the list of StructureDefinition section. The response content shall conform to these StructureDefinitions.

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.

Client - PHR

The PHR system requests the patient's GGZ information using individual search interactions over multiple FHIR resources. The client can use multiple individual search operations based on specified search queries. A search interaction can be performed by an HTTP GET or command as shown:

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

The table below shows in the first three columns the HCIM name in Dutch, in English and what HCIM content is requested. The last column shows the FHIR search queries to retrieve this information. The queries are based on the functional GGZ information exchange requirements, which are stated in the functional overview and shown in detail in this table. The queries, and more profoundly the response messages follow the profiles listed in the list of StructureDefinition section. The response content shall conform to these StructureDefinitions.

HCIM NL HCIM EN Content Search URL
Patient Patient Identification, birthdate, gender, deceasedindicator, contact details, marital status, legal status, and general practitioner (practitioner or organization)
GET [base]/Patient?_include=Patient:general-practitioner
BurgerlijkeStaat MaritalStatus Known marital status see Patient
Betaler Payer Insurance information
GET [base]/Coverage?_include=Coverage:payor:Patient&_include=Coverage:payor:Organization
BehandelAanwijzing TreatmentDirective All known treatment directives
GET [base]/Consent?category=http://snomed.info/sct|11291000146105
Wilsverklaring AdvanceDirective All known advance directives
GET [base]/Consent?category=http://snomed.info/sct|11341000146107
JuridischeStatus LegalStatus Known legal status see Patient and FreedomRestrictingMeasures procedure
VrijheidbeperkendeMaatregelen FreedomRestrictingMeasures All known freedom restricting measures see Procedure
Contactpersoon Contact First relation/contact see Patient.contact
FunctioneleOfMentaleStatus FunctionalOrMentalStatus All known functional / mental status
GET [base]/Observation?category=http://snomed.info/sct|118228005,http://snomed.info/sct|384821006
Probleem Problem All known problems
GET [base]/Condition
Druggebruik DrugUse All known drug use
GET [base]/Observation?code=http://snomed.info/sct|228366006
Alcoholgebruik AlcoholUse All known alcohol use
GET [base]/Observation?code=http://snomed.info/sct|228273003
Tabakgebruik TobaccoUse All known tobacco use
GET [base]/Observation?code=http://snomed.info/sct|365980008
Woonsituatie LivingSituation Last known living situation
GET [base]/Observation/$lastn?code=http://snomed.info/sct|365508006
Gezinssituatie FamilySituation All known family situations
GET [base]/Observation?code=http://snomed.info/sct|365470003
GezinssituatieKind FamilySituationChild All known family situations of child patient
GET [base]/Observation?code=http://snomed.info/sct|55801000146105
Taalvaardigheid LanguageProficiency Known language proficiency see Patient
ParticipatieInMaatschappij ParticipationInSociety All known participation in society status
GET [base]/Observation?code=http://snomed.info/sct|314845004
HulpVanAnderen HelpFromOthers All known help from others
GET [base]/CarePlan?category=http://snomed.info/sct|243114000
LaboratoriumUitslag LaboratoryTestResult Last known laboratory results per type (incl. medication levels like lithium)
GET [base]/Observation/$lastn?category=http://snomed.info/sct|275711006&_include=Observation:related-target&_include=Observation:specimen
AlgemeneMeting GeneralMeasurement All known questionaire (for example HONOS, OQ-45, CQ index, 4DKL) outcome scores.
GET [base]/Observation?category=http://hl7.org/fhir/observation-category|survey
Verrichting Procedure All known GGZ procedures (includes all known freedom restricting measures)
GET [base]/Procedure
TekstUitslag TextResult All known text results of GGZ procedures
GET [base]/DiagnosticReport
- - CareTeam: primary healthprofessional and other relevant healthprofessionals including the healthcare provider.
GET [base]/CareTeam?_include=CareTeam:participant
Zorgverlener HealthProfessional General Practitioner of the patient see Patient, CareTeam
Zorgaanbieder HealthProvider General Practitioner's organization of the patient see Patient, CareTeam

Server - XIS

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

Response to resource requests

If the search succeeds, the server SHALL return a 200 OK HTTP status code and the returned 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 returned content SHALL conform to the StructureDefinition applicable for the specific HCIM request. The list of a StructureDefinitions relevant for this use case is shown in the following paragraph: List of StructureDefinitions

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

Handling errors

If the search fails (cannot be executed, not that there are no matches), the return value is a status code 4xx or 5xx with an OperationOutcome. An 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. The HTTP status code 404 is returned if a XIS did not implement an endpoint used in a request by a PHR. When the search fails, a server SHOULD return an OperationOutcome detailing the cause of the failure. For example, in case of a not implemented FHIR endpoint, the OperationOutcome would state that the resource type is not supported. Note: an empty search result is not a failure.

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

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.

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

Interactions, operations, search parameters

Interactions

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

Operations

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. 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

The profiles represent their entire respective HCIM and are applicable in a broader context than the exchange of GGZ information.

Em.png

MedMij uses the FHIR Packaging mechanism. This conveniently bundles all examples, profiles and other conformance resources you need into a single download. For more background information see the the FHIR implementation guide. This version of the information standard depends on Nictiz package 1.1.4. Please note that the direct links to the various conformance resources below will take you to the latest version, which might not match the package version. At time of writing, there is no way to render the conformance resource as found in the package. This is on the roadmap for Simplifier.
HCIM NL HCIM EN FHIR Resource FHIR Profile
Patient Patient Patient http://fhir.nl/fhir/StructureDefinition/nl-core-patient
Betaler Payer Coverage http://nictiz.nl/fhir/StructureDefinition/zib-Payer
BehandelAanwijzing TreatmentDirective Consent http://nictiz.nl/fhir/StructureDefinition/zib-TreatmentDirective
Wilsverklaring AdvanceDirective Consent http://nictiz.nl/fhir/StructureDefinition/zib-AdvanceDirective
JuridischeStatus* LegalStatus* Extension see Patient or see FreedomRestrictingMeasures
VrijheidbeperkendeMaatregelen FreedomRestrictingMeasures Procedure http://nictiz.nl/fhir/StructureDefinition/zib-FreedomRestrictingMeasures
FunctioneleOfMentaleStatus FunctionalOrMentalStatus Observation http://nictiz.nl/fhir/StructureDefinition/zib-FunctionalOrMentalStatus
Probleem Problem Condition http://nictiz.nl/fhir/StructureDefinition/zib-Problem
Woonsituatie LivingSituation Observation http://nictiz.nl/fhir/StructureDefinition/zib-LivingSituation
Druggebruik DrugUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-DrugUse
Alcoholgebruik AlcoholUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-AlcoholUse
Tabakgebruik TobaccoUse Observation http://nictiz.nl/fhir/StructureDefinition/zib-TobaccoUse
Gezinssituatie FamilySituation Observation http://nictiz.nl/fhir/StructureDefinition/zib-FamilySituation
GezinssituatieKind FamilySituationChild Observation http://nictiz.nl/fhir/StructureDefinition/zib-FamilySituationChild
Taalvaardigheid LanguageProficiency Patient see Patient
ParticipatieInMaatschappij ParticipationInSociety Observation http://nictiz.nl/fhir/StructureDefinition/zib-ParticipationInSociety
HulpVanAnderen HelpFromOthers CarePlan http://nictiz.nl/fhir/StructureDefinition/zib-HelpFromOthers
LaboratoriumUitslag LaboratoryTestResult Observation http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation
AlgemeneMeting GeneralMeasurement Observation http://nictiz.nl/fhir/StructureDefinition/zib-GeneralMeasurement
Verrichting Procedure Procedure http://nictiz.nl/fhir/StructureDefinition/zib-Procedure
TekstUitslag TextResult DiagnosticReport http://nictiz.nl/fhir/StructureDefinition/zib-TextResult
Zorgverlener HealthProfessional Practitioner http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner
Zorgaanbieder HealthProfessional Organization http://fhir.nl/fhir/StructureDefinition/nl-core-organization
- - CareTeam http://fhir.nl/fhir/StructureDefinition/nl-core-careteam
* LegalStatus is a single concept of the HCIM FreedomRestrictingMeasures and does not represent a complete HCIM yet. This concept will become an indepentend HCIM in a future release of the HCIM.

Terminology, NamingSystems, Mappings

Terminology

Relevant ValueSets can be found through the ValueSet bindings in the listed StructureDefinitions. All ValueSets can be found here here and can be downloaded as a .zip in XML or JSON format.

NamingSystems

Relevant NamingSystems can be found here.

Mappings

Relevant HCIM to FHIR value set mappings can be found here. All profiles include HCIM mappings. HCIM concepts are mapped to the corresponding FHIR elements using the HCIMs concept id. The top of the StructureDefinition contains meta information regarding the HCIM mapping, such as the name and uri of the HCIM. In the StructureDefinition elements, the corresponding HCIM 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="hcim-patient-v3.1-2017EN"/>
        <uri value="https://zibs.nl/wiki/Patient-v3.1(2017EN)"/>
        <name value="HCIM Patient-v3.1(2017EN)"/>
    </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="hcim-patient-v3.1-2017EN"/>
                <map value="NL-CM:0.1.6"/>
            </mapping>
         </element>
     .....
</StructureDefinition>

Terminology, NamingSystems, Mappings

Terminology

Relevant ValueSets can be found through the ValueSet bindings in the listed StructureDefinitions. All ValueSets can be found here here and can be downloaded as a .zip in XML or JSON format.

NamingSystems

Relevant NamingSystems can be found here.

Mappings

A FHIR ConceptMap resource is provided when a FHIR value set is used instead of a HCIM value set. A ConceptMap maps the values between the two value sets. These ConceptMaps can be found here.

All profiles include HCIM mappings. HCIM concepts are mapped to the corresponding FHIR elements using the HCIMs concept id. The top of the StructureDefinition contains meta information regarding the HCIM mapping, such as the name and uri of the HCIM. In the StructureDefinition elements, the corresponding HCIM 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="hcim-patient-v3.1-2017EN"/>
        <uri value="https://zibs.nl/wiki/Patient-v3.1(2017EN)"/>
        <name value="HCIM Patient-v3.1(2017EN)"/>
    </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="hcim-patient-v3.1-2017EN"/>
                <map value="NL-CM:0.1.6"/>
            </mapping>
         </element>
     .....
</StructureDefinition>

Annex: Document history

Release notes

Release notes can be found on the functional design page.

History

Release Date Description
2019.01 - October 30-10-2019
  • Changes for 2019.01 October patch release
  • Added new version of FHIR package
2019.01 - September 30-09-2019
  • Added new version of FHIR package
2019.01 11-03-2019
  • MM-252: search url voor FreedomRestrictingMeasures weggehaald. Dit wordt door een request op Procedure afgehandeld.
2019.01 11-03-2019
  • Publication of changes in version 2019.01, conform release notes.
  • Moved release notes to the functional design page.
2019.01 11-03-2018 Added section "Terminology, NamingSystems, Mappings".
2018.06 18-10-2018 Corrected SNOMED code in search url for FunctionalOrMantalStatus.
2018.06 15-10-2018 Added version in title, and document history.