What is immunisation?
Immunisation is the process by which an individual’s immune system becomes fortified against an agent (known as the immunogen).
When this system is exposed to molecules that are foreign to the body, called non-self, it will orchestrate an immune response, and it will also develop the ability to quickly respond to a subsequent encounter because of immunological memory. This is a function of the adaptive immune system. Therefore, by exposing a person to an immunogen in a controlled way, the person’s body can learn to protect itself: this is called active immunisation.
What is a vaccination?
Vaccination is the administration of a vaccine to help the immune system develop protection from a disease. Vaccines contain a microorganism or virus in a weakened or killed state, or proteins or toxins from the organism. In stimulating the body’s adaptive immunity, they help prevent sickness from an infectious disease. When a sufficiently large percentage of a population has been vaccinated, herd immunity results. The effectiveness of vaccination has been widely studied and verified. Vaccination is the most effective method of preventing infectious diseases; widespread immunity due to vaccination is largely responsible for the worldwide eradication of smallpox and the elimination of diseases such as polio and tetanus from much of the world.
What immunisation data is GP Connect sending?
In GP Connect, what is sent in the Immunization resource is the event of a patient being administered a vaccination or where there is an intention to administer a vaccine which does not occur.
This may be a contemporaneous record by the clinician administering the vaccination (or by another member of the practice staff recording the event directly on behalf of the clinician) or it may be a record of an immunisation administered elsewhere as reported to the registered GP practice by the patient, a carer, guardian or other representative of the patient or another healthcare provider.
A record of an immunisation may be created as part of a scheduled programme of immunisations such as childhood immunisations, seasonal influenza vaccination or in response to specific circumstances (for example, prior to travel, disease outbreak or occupational risk).
If a vaccination is recorded as an issued medication, the details of the issued medication are not included in the immunisations response. The medication details MUST be sent as medication resources (if the consumer requests medications). This may be in addition to an immunisation resource for the event of the vaccination administration, depending on how the immunisation event was recorded.
Using the procedure code
GP clinical systems do not all record the full vaccine product (dm+d code) for an immunisation.
GP clinical systems often record the type of vaccine administered as opposed to the vaccine product.
This may be as a procedure code or a local code which can be mapped to a procedure code.
GP Connect, therefore, uses the vaccination procedure code to denote the vaccine being administered.
The vaccination procedure code is a mandatory element.
The vaccine product code will often be a nullFlavor code, but the actual vaccine product MUST be included if it is available.
Vaccinations that were not given
GP clinical systems may capture details of circumstances where an immunisation has not been given but there was an intention to. This version of the specification supports inclusion of intended vaccinations which were not given as defined by Digital Child Health. For details of the requirements see National Events Management Service - Vaccinations or versions as subsequently published. If the GP clinical system holds a coded record of an intended, not given vaccination which is either outside of the scope of the ‘not done’ situation codes or the required code is not available, then the coded information should be included in an uncategorised data response.
Consumers should be aware that the presence of a vaccination not given record is only in relation to an intended vaccination event on a given day - that is, it is not stating the vaccination has definitely never been given.
Populating elements for an immunisation not given
Specific rules are applied to the population of some of the elements where the record is for an intended immunisation which was not given. A few of these are highlighted here.
The provider MUST populate elements as described below when sending details of immunisations not given within the immunisation resource.
extension[vaccinationProcedure]MUST be the SNOMED CT ‘not done’ situation code for the vaccination which was intended but did not happennotGivenMUST betrueexplanation.reasonNotGivenSHOULD be included with the appropriate code for the reason the vaccination did not happen
See immunization for full details of the elements.
Consumer handling of immunisations not given
Consumer systems are to determine whether to request details of immunisations not given. A consumer system which requires not given immunisations MUST request this by specifying the part parameter. The default is to return given immunisations only.
Where a consumer system has requested immunisations not given, it MUST ensure that the not given data remains clearly distinct from given vaccinations. The consumer MAY need to handle explanation.reasonNotGiven alongside the “not done” code to provide the classified reason the vaccination was not given.
Additional information about vaccinations
The above section addresses circumstances where an immunisation is not given at the point of intending to give the vaccine.
GP Systems may capture other coded information relating to vaccinations other than the administration of the vaccine in an immunisations feature / module / categorisation.
This may be information regarding consent, dissent, invitations for vaccination, etc.
Where provider categorise such coded information as immunisation data, then it MUST only return it against an immunisation request.
GP Connect includes the parameter includeStatus to enable the consumer to specify the inclusion / exclusion of this information.
See Retrieve a patient’s structured record for full details of the parameter use.
Such coded records MUST be included with the immunisation bundle using an observation resource, as defined for uncategorised data.
Records returned against an immunisation request under the scope of this definition MUST be
- excluded from the records returned for an uncategorised data request
- included in the immunisations
List
Consumers shoud note than GP Systems differ with respect to additional information categorised as immunisations, therefore the same coded data may be returned against an immunisation or uncategorised data request by different provider systems.
Ended records
Where a GP clinical system allows a consent or dissent to be ended, then the observation.effective element MUST be populated with a Period including the relevant start and end dates.
This does not apply if the consent or dissent has been ended as “entered in error”, in which case the record MUST NOT be included.
Multiple records
If a patient record has multiple records of consent for a single type of vaccination, for example a dissent and a consent, then all records MUST be included.
Degraded records
Any records which the GP clinical systems classifies as an immunisation consent or dissent, but which do not appear in the hierarchies above MUST also be included. Where there is an appropriate code which is outside of the stated hierarchy, then that MAY be used. Where there is no identifiably appropriate SNOMED CT code for the consent or dissent, then the transfer degraded code MUST be used with a text element populated with the original text.
ConceptId - 196411000000103
DescriptionId - 294691000000115
Description - Transfer-degraded record entry
Ineffective vaccination
The Immunization FHIR profile contains elements to denote that a vaccination does not count towards immunity. This could be applied where a vaccination is suspected or found to be ineffective, for example as a result of a product recall or cold chain break. GP clinical systems do not have a standard means to identify an ineffective vaccination. Hence, immunisation records will always be returned as counting towards immunity.
Reactions to a vaccine
Allergic or adverse reactions to an immunisation may be captured in the GP clinical system, but these are not generally directly associated to the immunisation event.
It has not been considered reliable to link any allergic or adverse reaction to the immunisation record.
Therefore, information about reactions will not be included.
For details of allergies or adverse reaction, the AllergyIntolerance resource MUST be requested.
Immunisation schedules and recalls
The resources required to describe planned immunisation schedules are out of scope for this guidance. According to local practice, immunisations due may be recorded as recalls and retrieved via Diary entries.
Immunisation notes
GP systems that support a note entry against the immunisation MUST populate the text to the note element.
Additionally, any other information relevant to the immunisation which does not have a suitable, supported element within the Immunization resource MUST be populated to the note as a key value pair.
This includes where there is an element in the profile for the type of information, but the data type is not compatible with the way the data is recorded in the GP system.
For example, if the GP system holds the dosage information in a format which does not comply with the doseQuantity element’s Quantity datatype, then it may be returned as a note key value pair.
Using the List resource for immunisation queries
The results of a query for immunisation details MUST return a List containing references to all Immunization and Observation resources that are returned.
The List MUST be populated in line with the guidance on List resources.
If the List is empty, then an empty List MUST be returned with an emptyReason.code with the value no-content-recorded. In this case, List.note MUST be populated with the text ‘Information not available’.