Introduction to linkages between data items in GP Connect

Linkages

One of the purposes in developing the FHIR® profiles is to ensure that clinical data is, as much as possible, presented the same way regardless of the provider system. This ensures the consuming system (and clinician) will always know where to look for each type of information. However, information about the patient is not just held within the profiles but in how those profiles are linked together. For example, linking a medication to a problem means that as well as the record showing what the patient is taking, it also explains why they are taking it.

For a consuming system to be able to interpret this linkage information correctly, it needs to be presented in the same way regardless of the providing system.

Note: The diagrams are illustrative to support the specification text. There may be some simplifications or omissions, for instance not all possible linkages to the resources for investigations are shown.

GP Connect FHIR® model

To support this, GP Connect has developed a FHIR model that identifies all the GP Connect FHIR profiles and how they are related together to store the patient record.

The model currently covers Consultations, Problems, Medications and Medical Devices, Allergies, Immunisations, Uncategorised Data, Referrals, Investigations, Documents and Diary Entries. Other clinical areas will be added as they are developed.

The relationships between two FHIR profiles are recorded in only one of the linked FHIR profiles (similar to in a relational database management system). This is shown by the direction of the arrow in the FHIR model. For example, the MedicationStatement profile contains a field that can be used to look up the linked Medication. There is no field in the Medication profile that can be used to look up the linked MedicationStatement.

FHIR profiles returned on query

When a consumer system requests data on a clinical area the information may be returned across a number of FHIR profiles. Choosing which FHIR profiles to return is a balancing act between including enough linked profiles to give the consumer system a comprehensive response to their query but not including so many linked profiles as to swamp the consumer system with data.

The three main considerations used to decide which data to return for each clinical area were:

• include all the FHIR profiles required to fully describe the requested clinical area
• include the FHIR profiles required to define all the linkages from the requested clinical area
• include the FHIR profiles from linked clinical areas where they are key to understanding the requested clinical area

For each clinical area in a query that returns data a list should be generated that contains links to all data items returned for that clinical area. Some query responses will contain more than one list for a clinical area. The nature of the list can be determined from the list elements, see Using lists to return data for details.

Consultations and problems containing unsupported clinical items

Depending on the GP Connect version supported by the provider system it can be possible for the consultation or problem to link to a clinical item that the provider system is not yet able to export with GP Connect. For example, if the consultation contains a link to a referral record, but the provider system does not yet support exporting referrals.

Where a provider system is not able to export a linked clinical item, it will create a section.section.entry (or section.entry) entry with the:

• List.entry.item.display set to “[Clinical area] items are not supported by the provider system.”

  Where [Clinical area] identifies the type of the clinical item that is not supported.

The example below shows references to two items, one for an observation and another for referrals that aren’t supported by the provider system:

{
  "item": {
    "reference": "Observation/6734572634"
  }
},
{
  "item": {
    "display": "Referral items are not supported by the provider system"
  }
}

Consultations

When GP Connect returns a consultation it will supply the metadata of the consultation and all the clinical data that was recorded during the consultation.

The response to the query includes:

• A List profile containing references to Encounter for every Consultation that met the search criteria
• A List profile for each clinical area that data exists in the bundle

For each Encounter referenced in the List profile:

• The Encounter profile of the Consultation
• The List profiles that describe the structure of the Consultation
• The ProblemHeader (Condition) profile of any directly linked Problems
• The MedicationRequest, MedicationStatement and Medication profiles of any linked Medications or Medical Devices
  • Always include the MedicationStatement, MedicationRequest (intent = plan) and Medication profiles
  • Only include MedicationRequest (intent = order) for directly linked issues
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Medications and Medical Devices
• The AllergyIntolerance profile of any linked Allergies, including resolved allergies
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Allergies
• The Immunization profile of any linked Immunisations
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Immunisations
• The Observation profile of any linked Uncategorised Data
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Uncategorised Data
• The ReferralRequest profile of any linked Referrals
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Referrals
• The DocumentReference profile of any linked Documents
  • Only include the document metadata in any returned DocumentReference profile, do not include the binary file
  • In order to retrieve the binary file, a consumer must have been assured for the Access Document capability
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Documents
• The DiagnosticReport, ProcedureRequest, Observation, Specimen and DocumentReference profiles of any linked Investigations
  • Only include the document metadata in any returned DocumentReference profile, do not include the binary file.
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Investigation
• The ProcedureRequestprofile of any linked Diary Entries
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Diary Entries
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location.

Where a Consultation links to a profile that is not yet supported by the provider system then it is not included in the response. Details on how this is done can be found in the Consultation Guidance.

Clinical items within the Consultation are always included in the response regardless of their inclusion/exclusion in other parts of the query. So, for example, if a consumer requests consultations then any medications that are contained in the consultations returned will be present in the bundle, regardless of the medications parameter being absent or set to false in the request.

Problems

When GP Connect returns a problem it will supply the metadata and description of the problem and all the clinical data that has been linked to the problem.

The response to the query includes:

• A List profile containing references to ProblemHeader (Condition) for every Problem that met the search criteria
• A List profile containing references to ProblemHeader (Condition) for every Problem not meeting the search critieria but directly linked to a Problem which does meet the search criteria
• A List profile for each clinical area that data exists in the bundle

For each ProblemHeader (Condition) referenced in the List profile:

• The ProblemHeader (Condition) profile of the Problem
• The ProblemHeader (Condition) profiles of any directly linked Problems
• The Encounter profiles of any linked Consultations
• The MedicationRequest, MedicationStatement and Medication profiles of any linked Medications or Medical Devices
  • Always include the MedicationStatement, MedicationRequest (intent = plan) and Medication profiles
  • Only include MedicationRequest (intent = order) for directly linked issues
• The AllergyIntolerance profile of any linked Allergies
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Allergies
• The Immunization profile of any linked Immunisations
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Immunisations
• The Observation profile of any linked Uncategorised Data
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Uncategorised Data
• The ReferralRequest profile of any linked Referrals
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Referrals
• The DocumentReference profile of any linked Documents
  • Only include the document metadata in any returned DocumentReference profile, do not include the binary file.
  • In order to retrieve the binary file, a consumer must have been assured for the Access Document capability
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Documents
• The DiagnosticReport, ProcedureRequest, Observation, Specimen and DocumentReference profiles of any linked Investigations
  • Only include the document metadata in any returned DocumentReference profile, do not include the binary file.
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Investigation
  • Where an observation that represents a test or test group header has been made the actual problem then the ‘diagnosticReport’ it is from MUST be linked to the problem in the relatedClinicalContent extension.
• The ProcedureRequestprofile of any linked Diary Entries
  • Include the ProblemHeader (Condition) profile of any Problems linked to the returned Diary Entries
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Where a Problem links to a profile that is not yet supported by the provider system, then it is not included in the response. Details on how this is done can be found in the Problem Guidance.

Clinical items linked to the Problem are always included in the response regardless of their inclusion/exclusion in other parts of the query. So, for example, if a consumer requests a Problem that links to a Medication but does not explicitly request Medications in the query, the provider will still include the Medication linked to the Problem as part of its response.

Medications and medical devices

When GP Connect returns a medication or medical device it will supply the prescription plan information. Unless excluded by the consumer request, GP Connect will also return all the prescription issues made under the plan.

The response to the query includes:

• A List profile containing references to MedicationStatement for every Medication and Medical Device that met the search criteria
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each MedicationStatement referenced in the List profile:

• The MedicationStatement profile of the Medication or Medical Device
• The MedicationRequest (intent = plan) profile of the Medication or Medical Device
• The Medication profile of the Medication and Medical Device
• Where requested, the MedicationRequest (intent = order) profile for every issue
• The ProblemHeader (Condition) profiles of any directly linked Problems
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Allergies

When GP Connect returns an allergy it will supply all the allergy data.

The response to the query includes:

• A List profile containing references to AllergyIntolerance for every active Allergy
• Where requested, a List profile containing references to AllergyIntolerance for every ended Allergy
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each AllergyIntolerance referenced in either of the List profiles:

• The AllergyIntolerance profile of the Allergy
• The ProblemHeader (Condition) profiles of any directly linked Problems
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Immunisations

When GP Connect returns an immunisation it will supply all the immunisation data.

The response to the query includes:

• A List profile containing references to Immunization for every Immunisation and Observation for every consent / dissent to immunisation (referred to below as query response List profile)
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each Immunization referenced in the query response List profile:

• The Immunization profile of the Immunisation
• The ProblemHeader (Condition) profiles of any directly linked Problems

For each Observation referenced in the query response List profile:

• The Observation profile of the consent / dissent for immunisation
• The ProblemHeader (Condition) profiles of any directly linked Problems

For each Immunization and Observation referenced in the query response List profile:

• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Uncategorised data

When GP Connect returns uncategorised data it will supply all the data about the uncategorised data.

The response to the query includes:

• A List profile containing references to Observation for every Uncategorised Data that met the search criteria
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each Observation referenced in the List profile:

• The Observation profile of the Uncategorised Data
• The ProblemHeader (Condition) profiles of any directly linked Problems
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Referrals

When GP Connect returns a referral it will supply all the referral data.

The response to the query includes:

• A List profile containing references to ReferralRequest for every Referral that met the search criteria
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each ReferralRequest referenced in the List profile:

• The ReferralRequest profile of the Referral
• The ProblemHeader (Condition) profiles of any directly linked Problems
• The DocumentReference profiles of any directly linked Documents (do not include the Binary)
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Investigations

When GP Connect returns an investigation it will supply all the investigation information.

The response to the query includes:

• A List profile containing references to DiagnosticReport for every Investigation that met the search criteria
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each DiagnosticReport referenced in the List profile:

• The DiagnosticReport profile of the Investigation
• The ProcedureRequest profile of the Investigation
• The Specimen profiles of the Investigation
• The Observation profiles of the Investigation
• The DocumentReference profiles of the Investigation
  • Only include the document metadata in any returned DocumentReference profile, do not include the binary file.
• The ProblemHeader (Condition) profiles of any directly linked Problems
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Diary entries

When GP Connect returns a diary entry it will supply all the diary entry data.

The response to the query includes:

• A List profile containing references to ProcedureRequest for every Diary Entry that met the search criteria
• A List profile containing references to each ProblemHeader that is contained in the bundle

For each ProcedureRequest referenced in the List profile:

• The ProcedureRequest profile of the Diary Entry
• The ProblemHeader (Condition) profiles of any directly linked Problems
• All administrative profiles referenced directly (or via another administrative profile) by any of the clinical profiles included above
  • Include Patient, Organization, PractitionerRole, Practitioner and Location

Problem and Consultation linkages

The sections above show general details of the linkages for problems or consultations responses. This section looks at the representation of problem and consultation linkages, when consultations have been requested. Providers SHOULD return all references between all resources wherever possible and include the actual clinical item which relates to the problem header whether the actual problem item or a subsequent recording of the problem.

The example below represents a simple case of a consultation and its content which all relates to a single, new problem.

• The problem header references to the consultation, the consultation topic, the actual problem and any other content of the consultation
• The consultation topic references the problem header
• The actual problem is included as a resource (an uncategorised data observation in this case) and references the consultation
• All other content of the consultation references the consultation and is referenced by the problem header

This further example represents a subsequent consultation which includes further information related to the problem above and other information related to a new problem recorded in the same consultation. The consultation content relating to the existing and new problem is represented as described above, except the existing problem is shown with a new instance of a clinical item which is the same term.

Multiple clinical areas requests

The details above have described the response a request for a single clinical area. The consumer may include more than one clinical area in a request. The request must be compliant with the criteria for multiple parameters as described in API Definition - Retrieve a patient’s structured record

In responding to a valid multiple parameter request, the provider must return lists and resources as defined above for each clinical area included in the request. In addition, the provider must return List resources as described in Using lists to return data This may result in consolidated or multiple List profiles for clinical areas. The following models demonstrate this.

This model is an example of a request for medications and allergies. It is included to show how related problem references are consolidated into a single List profile where more than one clinical area has been requested. This applies regardles of which clincial areas or how many clinical areas are included in the request.

This model is an example of a request for consultations, problems, medications and allergies. It also includes a consolidated related problems List profile, but is included to show the multiple List profiles returned due to the inclusion of

• a primary list for each of the requested clinical areas
• secondary lists for all clinical areas contained in consultations or linked to problems, regardless of inclusion in the request

Duplicate returned profiles

Where the same instance of a profile is returned from multiple query responses (for example a medication is returned as part of the medication search and the consultation search), it will only be included once in the response message.

The details on how this is implemented in an API can be found in the API definition.