MedMij FHIR Implementation Guide: BgZ 2.1.13

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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 StructureDefinitions.

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.

2 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

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 Interactions between client and server

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Interactions are initiated by the client (PHR) according to the RESTful mechanism. The following interactions, operations and search parameters are relevant for exchanging the BgZ:

RESTful interactions: search
Operations: Last N Observations Query
Search parameters Parameter types: token (including modifier 'in')


Paramerers used: _include

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 Client requests - PHR

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 interaction can be performed by an HTTP GET or command as shown:

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

The table below shows the BgZ sections, the HCIMs that constitute those sections and the StructureDefinitions (FHIR profiles) that implement them. The profiles represent their entire respective HCIM, to make them applicable outside the context of BgZ or MedMij. The last column shows the FHIR search queries that the client needs to use to obtain the BgZ information.

BgZ section Content HCIM EN FHIR Profile(s) Search URL
1. Patient information Identification, birth date, gender, deceased indicator, contact details, last known marital status Patient
GET [base]/Patient?_include=Patient:general-practitioner

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

Example instances of FHIR resources can be found on Simplifier. Please note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of any information standard.

4.2 Server responses - XIS

4.2.1 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 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 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:

    <relation value="self"/>
    <url value="[Patient-ID]/>

Link to the relevant FHIR specification:

4.2.2 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 date/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:

5 Terminology, NamingSystems, Mappings

5.1 Terminology

Relevant value sets can be found using the ValueSet category. 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'.

5.2 NamingSystems

Relevant NamingSystems can be found using the NamingSystem category.

5.3 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.

An explanation about mappings can be found at Mapping of coded concepts.

6 Release notes

Release notes can be found on the functional design page.