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Intervention FHIR Mappings

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Chris Moesel edited this page Nov 19, 2015 · 2 revisions

In HL7 FHIR, the Order resource "describes a request that an action be performed." The specification further clarifies that orders "require real world actions by one or more humans." As such, it is likely the best representation of planned interventions (as opposed to using specific order resources directly). See the specification for more details.

Order resources contain a reference to the more specific order that is being requested. As such, storing an intervention will actually require two resources to be stored: (1) The Order resource, and (2) the more specific resource described by the order. There are two approaches to doing this:

  1. Separate Requests: First store the specific order resource. Next store the Order resource with a reference to the returned ID of the specific order resource.
  2. Bundle: Create a bundle containing both the Order resource and the more specific order resource. Submit the bundle to the server as a transaction.

Option 2 (as a bundle) seems to be the more idiomatic approach, so this is the approach I would suggest. That said, if this presents problems for Ember, the separate requests approach can be used instead.

NOTE: After documenting all of the details, I can see that both approaches are fairly complicated, particularly for the frontend. We may want to consider a simplified API for the frontend, with the full FHIR mapping happening in the backend. Another approach might be not to use FHIR at all for storing planned interventions (as I do have some concerns regarding how that works as well). This is something that should be discussed further.

General Bundle approach

Rather than repeat the same bundle format over and over for each intervention definition, I will show how it generally works here, and then indicate the specific order resource information for each intervention type.

The bundle should specify the type as transaction.

The first entry in the bundle should be the Order. The Order resource should supply the following fields:

  • text: the text that the user entered for the intervention details (must be xhtml)
  • date: the date the intervention was created/planned
  • subject: a reference to the patient who should receive the intervention
  • source: a reference to the user (a practitioner) who created the intervention
  • target: a reference to the user (a practitioner) who is assigned to do the intervention
  • detail: a reference to the specific order resource describing the intervention. Since this is a transaction bundle, the reference should be to the urn specified in the second entry.

The second entry in the bundle is the specific order resource. It should have the proper status to indicate it is proposed/planned/etc.

The following is an example of the Schedule Appointment intervention:

{
  "resourceType": "Bundle",
  "type": "transaction",
  "entry": [
    {
      "fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a",
      "resource": {
        "resourceType": "Order",
        "text": {
          "status": "additional",
          "div": "<div>Schedule an appointment in the next two weeks to come in and receive a physical exam.</div>"
        },
        "date": "2015-11-16@14:30:00-04:00",
        "subject": {
      		"reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
      	},
        "source": {
      		"reference": "Practitioner/685fd42a-fbed-1867-1a87-d89f6e52a175"
      	},
        "target": {
      		"reference": "Practitioner/186d8fe2-acbd-9658-35f7-123ad8fe698a"
      	},
        "detail": {
      		"reference": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059"
      	},
      },
      "request": {
        "method": "POST",
        "url": "Order",
      }
    },
    {
      "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
      "resource": {
        "resourceType": "Appointment",
        "status": "proposed",
        "participant": [{
            "actor": {
          		"reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
          	},
            "required": "required",
            "status": "needs-action"
        }]
      },
      "request": {
        "method": "POST",
        "url": "Appointment"
      }
    }
  ]
}

Schedule Appointment

The Schedule Appointment intervention should be an Order that references an Appointment. The Appointment has the following fields:

  • status: set to proposed
  • participant: at least one participant is required, so we use the patient:
    • actor: a reference to the patient
    • required: set to required
    • status: set to needs-action

The following is an example of the second bundle entry with the embedded Appointment resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "Appointment",
    "status": "proposed",
    "participant": [{
        "actor": {
          "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
        },
        "required": "required",
        "status": "needs-action"
    }]
  },
  "request": {
    "method": "POST",
    "url": "Appointment"
  }
}

Home Visit

The Home Visit intervention is very much like the Schedule Appointment intervention. The only difference is that it contains an additional participant to represent the location (home). This participant has the following values:

  • actor: a reference to the location (defined in the 3rd entry of the bundle)
  • required: set to required
  • status: set to needs-action

The following is an example of the second bundle entry with the embedded Appointment resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "Appointment",
    "status": "proposed",
    "participant": [{
        "actor": {
          "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
        },
        "required": "required",
        "status": "needs-action"
    }, {
        "actor": {
          "reference": "urn:uuid:5d689ae5-24ad-f568-225a-9354ad6ef875"
        },
        "required": "required",
        "status": "needs-action"
    }]
  },
  "request": {
    "method": "POST",
    "url": "Appointment"
  }
}

In addition, the bundle must include a 3rd entry to indicate the location. The location must have the following fields:

  • name: set to home
  • type: a CodeableConcept with the code PTRES
  • physicalType: a CodeableConcept with the code ho

The following is an example of the third bundle entry with the embedded Location resource:

{
  "fullUrl": "urn:uuid:5d689ae5-24ad-f568-225a-9354ad6ef875",
  "resource": {
    "resourceType": "Location",
    "name": "home",
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/v3/RoleCode",
          "code": "PTRES",
          "display": "Patient's Residence"
        }
      ]
    },
    "physicalType": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/location-physical-type",
          "code": "ho",
          "display": "House"
        }
      ]
    }    
  },
  "request": {
    "method": "POST",
    "url": "Location"
  }
}

Phone Call

The Phone Call intervention should be an Order that references a CommunicationRequest. The CommunicationRequest has the following fields (some of which are redundant with the Order):

  • sender: a reference to the practitioner assigned the intervention
  • recipient: a reference to the patient who is to receive the phone call
  • medium: a CodeableConcept with code PHONE
  • status: set to proposed
  • requester: a reference to the user who created the planned intervention
  • requestedOn: when the intervention was created
  • subject: a reference to the patient

The following is an example of the second bundle entry with the embedded CommunicationRequest resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "CommunicationRequest",
    "sender": {
      "reference": "Practitioner/186d8fe2-acbd-9658-35f7-123ad8fe698a"
    },
    "recipient": {
      "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
    },
    "medium": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/v3/ParticipationMode",
          "code": "PHONE",
          "display": "telephone"
        }
      ]
    },    
    "status": "proposed",
    "requester": {
      "reference": "Practitioner/685fd42a-fbed-1867-1a87-d89f6e52a175"
    },
    "requestedOn": "2015-11-16@14:30:00-04:00",
    "subject": {
      "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
    }   
  },
  "request": {
    "method": "POST",
    "url": "CommunicationRequest"
  }
}

Medication

The Medication intervention should be an Order that references a MedicationOrder. The MedicationOrder has the following fields:

  • status: set to draft
  • patient: a reference to the patient who should be prescribed the medication
  • prescriber: a reference to the practitioner who should prescribe the medication
  • medication: a CodeableConcept with only the text set to the medication details. The medication field is required, which is why we have to put something there.

The following is an example of the second bundle entry with the embedded MedicationOrder resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "MedicationOrder",
    "status": "draft",
    "patient": {
      "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
    },
    "prescriber": {
      "reference": "Practitioner/186d8fe2-acbd-9658-35f7-123ad8fe698a"
    },
    "medication": {
      "text": "Lisinopril 10mg"
    }
  },
  "request": {
    "method": "POST",
    "url": "MedicationOrder"
  }
}

Diet

The Diet intervention should be an Order that references a NutritionOrder. The NutritionOrder has the following fields:

  • patient: a reference to the patient who should be put on the diet
  • orderer: a reference to the practitioner who should order the diet
  • status: set to proposed

The following is an example of the second bundle entry with the embedded NutritionOrder resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "NutritionOrder",
    "patient": {
      "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
    },
    "orderer": {
      "reference": "Practitioner/186d8fe2-acbd-9658-35f7-123ad8fe698a"
    },
    "status": "proposed"
  },
  "request": {
    "method": "POST",
    "url": "NutritionOrder"
  }
}

Exercise

The Exercise intervention should be an Order that references a ProcedureRequest. The ProcedureRequest has the following fields:

  • subject: a reference to the patient who should be ordered to exercise
  • code: a CodeableConcept containing the SNOMED-CT code 281090004
  • status: set to proposed
  • orderer: a reference to the practitioner who should order the exercise

The following is an example of the second bundle entry with the embedded ProcedureRequest resource:

{
  "fullUrl": "urn:uuid:88f151c0-a954-468a-88bd-5ae15c08e059",
  "resource": {
    "resourceType": "ProcedureRequest",
    "subject": {
      "reference": "Patient/497fd901-bedc-7634-75f3-156a8f74d55e"
    },
    "code": {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "281090004",
          "display": "Recommendation to exercise"
        }
      ]
    },  
    "status": "proposed",
    "orderer": {
      "reference": "Practitioner/186d8fe2-acbd-9658-35f7-123ad8fe698a"
    },
  },
  "request": {
    "method": "POST",
    "url": "ProcedureRequest"
  }
}
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