Clinical Notes in FHIR

10/02/2018

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Update from prior Patient Care/Structured Documents

joint session on 5/15/2018

Agenda

Notes in FHIR

Argonaut Priority�Overview and update from discussions at Connectathon

Discuss note access scenarios

Latest design

Next steps

Notes in FHIR

Minimal guidance today�Full Agreement FHIR needs specific guidance to exchange notes

Patient Care Work Group considered these resources:

• Observation
• DocumentReference
• Composition
• New Notes Resource

11/30/2017 - PC discussion, agreed to explore Composition

01/29/2018 - PC/SD discussion, agreed to proceed with DocumentReference � for May 2018 connectathon track

05/15/2018 - May Connectathon - DocumentReference

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Argonaut Priority - Clinical Notes

Goal: Clear guidance for accessing Clinical Notes with FHIR

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Success criteria

• Define a consistent way to create and fetch Clinical Notes
• Implemented by several Argonaut participants
• Create one or more profiles to support consistent implementations
• Establish clear query definitions
• Future: guidance is added to HL7 US Core

Clinical Notes Timelines

Common Clinical Notes Set

Common Clinical Notes Set

• Discharge documentation (18842-5)
• Consultation (11488-4)
• History & Physical (34117-2)
• Progress note (11506-3)
• Procedures note (28570-0)
• Future Imaging narrative (18726-0) and Lab/path narrative

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….Transfer note, Referral note, Surgical Operation note, Nurse note, Care Plan

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Starter Set for testing and design - the value set will not be restricted to these 7

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6

Anticipated Note Formats

Increasing

Level of Complexity

Progress Note

Scenario 1: Text or XHTML

DocumentReference

…

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Reference a Binary Resource

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[base]/Binary

Scenario 2: RTF or PDF

DocumentReference

…

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[base]/Binary

Reference a Binary Resource

Scenario 3: Mixed – structured FHIR resources, and narrative

May have 2:

1 Binary Resource (e.g. C-CDA)

2 Composition

[base]/Binary

[base]/Composition

DocumentReference

…

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Clinical Notes with DocumentReference

The following are example usage scenarios for the Argonaut Clinical Notes profile:

• Query for a specific Clinical Note type (e.g. Discharge Summary)
• Query for all Clinical Notes belonging to a Patient
• Write a new Note to a Patient’s Chart

Minimum support:

18842-5 Discharge summary�11488-4 Consult note �34117-2 History and physical note �11506-3 Progress note �28570-0 Procedure note

�Additional Note support expected for LOINC values whose SCALE is DOC in the LOINC database.

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Connectathon Scenarios

1. Retrieve an Encounter Summary Note with DocumentReference/id
2. Retrieve all notes by patient
3. Retrieve an Encounter Summary Note searching with a date range
4. Retrieve a Patient's Discharge Summary Notes
5. Retrieve a Patient's Radiology Notes
6. Write a new note to a Patient's Chart
7. Bonus: Implement the $expand operation

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Clinical Notes Track Scenario and Report out!

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Two use cases to consider

Get all documents (e.g. Discharge Summary, Consultation Note, Laboratory Report, Cardiology Report, Radiology Report etc.)

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Get all diagnostic test data (such as CBC, EKG) that may be represented as either a scanned document or fully discrete

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How does a Client know which resource to query?

Proposed Solution

When DiagnosticReport.presentedForm (Attachment) references a PDF/Scan, then that Attachment SHALL also be accessible through DocumentReference.content.attachment.

• When a diagnostic test has a document in presentedForm, that document will be referred to by both a DiagnosticReport and DocumentReference. Representing these in both resources allows a client to query a single resource.

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This is the only way to guarantee a Client doing a query only one resource won’t be missing information!

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The DocumentReference and DiagnosticReport resources representing the same data will point to the same attachment, so a client can easily identify these duplicates.

• DocumentReference.content.attachment.url
• DiagnosticReport.presentedForm.url

Standard DiagnosticReport.category codes

New LOINC Parts codes:

• LP29684-5 Radiology
• LP29708-2 Cardiology
• LP7839-6 Pathology�

What are LOINC Parts? (LOINC User Guide)

• Coded representation of a value for a dimension used to specify a LOINC term.
• LOINC parts support the translation of LOINC terms into other languages, easy linking of synonyms across many terms, and the creation of hierarchies to group related LOINC terms
• The intended use of the LOINC parts and LOINC part hierarchies are to organize or be constituents of LOINC terms.

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$expand ValueSet Operation

http://build.fhir.org/valueset-operation-expand.html

http://test.fhir.org/r3/ValueSet/$expand?context=DiagnosticReport.category

http://test.fhir.org/r3/ValueSet/$expand?context=DocumentReference.category&contextDirection=incoming

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Patient Care Questions

Does anyone object to continue design which includes both DiagnosticReport and DocumentReference?

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Who is interested in January Connectathon track?

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