MedMij FHIR Implementation Guide: iWlz 1.0 Proof of concept (1.0-poc8)

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1 Introduction

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This page describes the exchange of iStandaard Wet langdurige zorg (iWlz) related resources using the HL7 FHIR standard. This page and all the materials provided on it are in beta version, with a goal of testing the exchange trough a Proof of Concept (PoC) within MedMij.

This IG is a technical representation of the functional design and follows the principles of the general MedMij FHIR IG.

2 Actors involved

The table shows the relevant actors, systems and FHIR CapabilityStatements. The CapabilityStatements demonstrate the minimum conformance requirements for the described use cases.

Actors Systems FHIR CapabilityStatements
Name Description Name Description Name Description
Client The user of a personal healthcare environment PHR Personal health record CapabilityStatement: Client FHIR Client requirements
Healthcare professional The user of a XIS XIS Healthcare information system CapabilityStatement: Server FHIR Server requirements

3 Boundaries and relationships

Go to Afsprakenstelsel

This FHIR implementation guide assumes that the PHR system is able to make a connection to search resources at the XIS. 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 'MedMij Afsprakenstelsel'.

The MedMij 2020.01 FHIR IG is applicable to the PoC mentioned in the introduction, unless specifically noted. Some parts of this IG, where noted, are only relevant to the PoC.

Because of the specific use cases to be tested within the PoC, 'closed modeling' as specified in the FHIR STU3 Profiling Guidelines has been chosen over 'open modeling'. This allows implementers to focus on the elements that are needed for a successful exchange within the PoC. It is expected that in future versions, 'open modeling' will again be preferred in line with other information standards.

There are two pairs of Questionnaire/QuestionnairResponse resources used within this standard, one of which is being used to capture Client input. For the PoC this Questionnaire is assumed to be static. In future iterations, the use case could be extended to first retrieve the latest version of the Questionnaire from the XIS that will be used by the client to provide a QuestionnaireResponse, which is the use case of the Questionnaires information standard. Discussions on how this standard would incorporate the Questionnaires standard are ongoing.

Within the PoC, 'abonneren' (subscribe) and 'notificeren' (notify) mechanisms are to be tested. These mechanisms are not part of the FHIR IG, their specifications can be found at MedMij Afsprakenstelsel (abonneren, notificeren).

4 Use case: retrieve 'indicatiegegevens'

The 'indicatiegegevens' are built up of individual FHIR resources, selected by the user of the XIS to form a coherent set of information relevant to the client. The Composition resource assembles the references to all individual related FHIR resources. For this purpose, the Composition profile described in FHIR profiles SHALL be used.

The PHR can retrieve all available Composition resources and all referenced resources as a single searchset Bundle by using the following custom operation[1]:

GET [base]/Composition/$indicaties

The result is a searchset Bundle with all Compositions available and all referenced resources. Note: the Composition lists just the resources that act as entry points for the various concepts in the transaction, but each of these referenced resources may further refer to other resources not listed there. The server SHALL produce a complete Bundle containing not only the resources listed directly in the Composition, but all the indirectly referenced resources as well.

The Compositions returned can be sorted and/or presented to the user by the PHR based on Composition.event.period to determine active and/or the most recent 'indicatie'.

Because each Composition resource and the resources it references are a set of coherent resources that are a representation of the 'indicatie' and that cannot be interpreted individually, XIS Servers are not expected to support resolving the individual resources of the Composition document Bundle by their fullUrl. PHR systems should only use the document operation to retrieve the 'indicatie' in full.

The data returned to the PHR should conform the profiles listed in the table below and (if applicable) their associated HCIMs. The resources in the response message SHALL be a valid instance of these profiles.

Profile name FHIR Resource Based on HCIM Canonical
iwlz-Indicatie Composition
iwlz-Beperking Observation
iwlz-BeperkingScore Observation
iwlz-Persoon Patient Patient
iwlz-GeindiceerdZorgzwaartepakket-Questionnaire Questionnaire
iwlz-GeindiceerdZorgzwaartepakket-QuestionnaireResponse QuestionnaireResponse
iwlz-Stoornis Condition
iwlz-StoornisScore Observation
The following nl-core profiles are used to reference an Organization in the iwlz-Indicatie
nl-core-practitionerrole PractitionerRole
nl-core-organization Organization HealthcareProvider

4.1 Custom Operation

The following custom operation is used:

5 Use case: send client profile

This use case applies when a client qualifies for receiving long term care based on the WLZ and the client wants to share his preferences, contact information and contact persons.

The client preferences are based on a iwlz-Clientvoorkeuren-Questionnaire resource to be filled by the client, leading to an iwlz-Clientvoorkeuren-QuestionnaireResponse resource. The contact information and contact persons filled in or edited by the client lead to an edited iwl-Persoon Patient resource.

5.1 Send transaction Bundle

The PHR initiates a FHIR transaction by sending an HTTP POST request composed of a FHIR Bundle resource containing one QuestionnaireResponse resource and one Patient resource to the XIS's base endpoint as shown below.

POST [base]

In this transaction Bundle, both the Patient resource and the QuestionnaireResponse have an entry.request.method of 'POST' (create interaction).

Note: because the PHR's client can only edit several parts of the resource, the create interaction does not force the server to accept the entire resource as is. For example, the updated content may be reviewed before merging it with the exisitng information. Performing a read interaction on the Patient resource shortly after 'POST'ting an edited version may therefore lead to unexpected results. See the FHIR specification on transactional integrity for more discussion. However, it is the responsibility of the server to maintain only one version of the Patient resource.

Because of the static nature of the iwlz-Clientvoorkeuren-Questionnaire within this PoC, see also this paragraph, there is no explicit connection between the QuestionnaireResponse and the Questionnaire resources using the QuestionnaireResponse.questionnaire element. The PHR can use any preferred method to compose the QuestionnaireResponse resource, as long as it conforms to the profile. For each QuestionnaireResponse.item, the PHR SHOULD fill the .item.text element with the exact text that is used during user input.

The PHR shall guarantee consistency of all FHIR resource elements with the profiles listed in the table below and (if applicable) their associated HCIMs. The resources in the request message SHALL be a valid instance of these profiles.

Profile name FHIR Resource Based on HCIM Canonical
iwlz-Persoon Patient Patient
iwlz-Voorkeurscriteria-Questionnaire Questionnaire
iwlz-Voorkeurscriteria-QuestionnaireResponse QuestionnaireResponse

6 Additional remarks

6.1 Terminology

Discussions with Zorginstituut Nederland are ongoing on how to release and maintain their terminology resources. At the moment, a ValueSet and CodeSystem per 'codelijst' and bound to the applicable elements in the profiles. The CodeSystem resources do not contain the actual codes. These can be found at [1] (Excel-file). Notable exception is COD1001, which is available on GitHub.

6.2 Use of Questionnaire and QuestionnaireResponse profiles

According to the FHIR specification, a QuestionnaireResponse resource can be validated against its Questionnaire counterpart. However, it is unclear if this is supported by validators. Furthermore, it is not clear if the Questionnaire profiles and instances will actually be used in the process of composing the QuestionnaireResponse resource. Therefore, both a Questionnaire and a QuestionnaireResponse profile have been created for 'Geindiceerd Zorgzwaartepakket' and 'Clientvoorkeuren'. The QuestionnaireResponse profile describes the exact information exchange between systems and can be used for validation purposes.

7 Release notes

Release notes can be found on the functional design page.

  1. Originally, this was a two step process using the FHIR core $document operation. However, this use case does not match the intended use of this operation. Discussions are ongoing on the introduction of a new operation in a future version of FHIR to be able to search and retrieve document Compositions simultaneously, see the OperationDefinition for more information.