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Working drafts of HL7™ FHIR® Release 4 (R4) artefacts authored and maintained by the Informatics Architecture team at the Australian Digital Health Agency.
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ValueSet - Composition.status - support exchange of appropriate content #57

Closed dtr-agency closed 3 years ago

dtr-agency commented 4 years ago

Prerequisites

The feature

Description

We need to create a more constrained value set for the status element of Composition profiles. The usage scenarios most CI Agency Composition profiles are intended to support are the exchange of current valid electronic healthcare information between healthcare providers, and between healthcare providers and the My Health Record system.

The values must be drawn from the required CompositionStatus ValueSet. Possibly the new ValueSet may contain the codes of "final" and "amended" and exclude the codes of "preliminary" and "entered-in-error".

This new constrained ValueSet from CompositionStatus would be bound to Composition profiles in the forthcoming Diagnostics Report FHIR implementation Guide, and is expected to be used in Continuity of Care (e.g. Discharge Summary).

This does not mean that there will not be a need for systems to mark compositions as 'entered-in-error' or 'withdrawn' but these values are not meaningful in the exchange usage scenarios the Composition profiles are intended to support.

This new constrained ValueSet from CompositionStatus would not be used directly in CDA implementation guides; but it may inform the need for Version 2 of the current ValueSet Australian Healthcare Clinical Document Architecture Document Lifecycle Status which is bound as required in all Agency CDA implementation guides to date.

What it actually enables people to do

Clarifies to implementers requirements for the state of the composition in an exchange of health information for the purposes of the provision of healthcare. Provision of management of the set of values in a governed manner that is reusable across multiple profiles.

How awesome would it be?

Pretty awesome - clarity of requirements is always desired, and management by terminology binding is the preferred means in CI Agency profiles of specifying more than one allowed values for an element. This contributes to minimising the risk of inappropriate, invalid or obsolete clinical content.

Workarounds

There are other means of specifying controls on the membership of values including invariants, or alternatively only implementation guidance could be provided instead of a machine processable format.

Additional context

dtr-agency commented 4 years ago

This ValueSet when developed will be bound as required in Composition.status as part of:

UPDATE: More than one ValueSet has been proposed. The ValueSet intended to be bound in the above tickets is CompositionStatus Document Available https://healthterminologies.gov.au/fhir/ValueSet/compositionstatus-document-available-1

dtr-agency commented 4 years ago

Analysis of codes in the required value sets

Analysis of possible usage of codes in CompositionStatus Code Applicable doc type In / Out for diagnostic report Rationale
preliminary DS, Path Report, DI Report, Other Diag Report, Care Plans? In It is common and meaningful to send a diagnostic report with initial results with a final to follow. It may also be a reasonable state for sharing with Discharge Summaries, Care Plans, and other content. Not expected to be appropriate for document types such as Shared Health Summaries, Prescriptions, Dispense Records, etc.
final All doc types In This is value is meaningful in all usage scenarios supported by Agency CI models; it is the desired state of the some content.
amended Most doc types In This is value is meaningful in most usage scenarios; query whether this can be supported in the My Health Record system. There are likely to be some workflows that will not support this value; they may be able to be served by fixing the value of status to final in a profile or via some other mechanism for specific implementations.
entered-in-error N/A Out This value does not support our usage scenarios; it indicates an undesirable state outside of the scope of the scenarios

The above shallow analysis suggests there is a need for two ValueSets - one for where a preliminary document may be provided prior to a final document (then amended), and one for where only a final document (then amended) makes sense to be sent.

Analysis of possible usage of codes in Australian Healthcare Clinical Document Architecture Document Lifecycle Status Code Applicable doc type In / Out for diagnostic report Rationale
W N/A Out This value does not support our usage scenarios; it indicates an undesirable state outside of the scope of the scenarios - it is not used in exchange aka a document with 'withdrawn' is not sent to indicate that a document is 'withdrawn'.
F All doc types In This is value is meaningful in all usage scenarios supported by Agency CI models; it is the desired state of the some content. When a CIS supersedes a clinical document on the My Health Record System, it uploads a new clinical document overriding a previously uploaded document.
I DS, Path Report, DI Report, Other Diag Report, Care Plans? In It is common and meaningful to send a diagnostic report with initial results with a final to follow. It may also be a reasonable state for sharing with Discharge Summaries, Care Plans, and other content. Not expected to be appropriate for document types such as Shared Health Summaries, Prescriptions, Dispense Records, etc.

The above shallow analysis suggests that some ClinicalDocument templates should move to fixing the status to be F (Final), and some should move to an updated ValueSet of F (Final) and I (Interim) which could be version 2 of the existing value set.

Other notes: it is possible that W 'withdrawn' is a marker of consent withdrawn rather than document withdrawn due to error - if this is the case then the ConceptMap has a defect where W is mapped to entered-in-error as equivalent.

Queries with BAs: Q. Are there any currently supported document types in the My Health Record that allow for the 'update' (superseding) of a of a clinical document as in makes use of setId and version to indicate that this is a later version of the same document? Or are all updates occurring via superseding to a different clinical document that is the latest? that may or may not involve removing the clinical document that is being superseded. A. Depending on the doc type and implementations, documents may be superseded by a new version of the same document or by a new document. In the first case that may be an interim moving to final, or it may be a final superseded by a final (ostensibly amended). A.

dtr-agency commented 4 years ago

@udaychandrupatla and @vikasmittal-dh, can you confirm if there are any schematron tests restricting the values for status (i.e. ClinicalDocument/ext:completionCode) in any of the template packages beyond just checking it is one of the three codes in Australian Healthcare Clinical Document Architecture Document Lifecycle Status?

udaychandrupatla commented 4 years ago

The only values allowed in the template packages which are currently in My Health Record are the following three.

   code="I" displayName="Interim"   codeSystemName="NCTIS Document Status Values" codeSystem="1.2.36.1.2001.1001.101.104.20104"
    code="F" displayName="Final"     codeSystemName="NCTIS Document Status Values" codeSystem="1.2.36.1.2001.1001.101.104.20104"
    code="W" displayName="Withdrawn" codeSystemName="NCTIS Document Status Values" codeSystem="1.2.36.1.2001.1001.101.104.20104"

In any of the previous template packages we have not restricted them any further.

But going forward starting from PSML stage 2 template packages, we will only check for

dtr-agency commented 4 years ago

@udaychandrupatla and @vikasmittal-dh, thanks for confirming there are no schematron tests restricting the values for status any further than one of the three codes in Australian Healthcare Clinical Document Architecture Document Lifecycle Status in a template package.

dtr-agency commented 4 years ago

Suggested outcomes:

  1. A new ValueSet for Composition.status containing the codes: 'preliminary', 'final', 'amended'
  2. A new ValueSet for Composition.status containing the codes: 'final', 'amended'
  3. A new ValueSet for ClinicalDocument/ext:completionCode containing the codes: 'F', 'I'
  4. Two new ConceptMaps to go between the 1st Composition.status ValueSet and the new ValueSet for ClinicalDocument/ext:completionCode

Query on 3. Should this be a new ValueSet rather than a major version update? @LB-Agency - thoughts? A. Resolved to be a new ValueSet.

The original point 5. of two new ConceptMaps to go between the 2nd Composition.status ValueSet and the updated ClinicalDocument/ext:completionCode has been withdrawn now that we are authoring a new ValueSet for ClinicalDocument/ext:completionCode. It is not necessary or needed to map the CompostionStatus Document Final status to the wider CDA Document Available status set.

dtr-agency commented 4 years ago

ValueSet Design Notes

1. A new ValueSet for Composition.status containing the codes: 'preliminary', 'final', 'amended'

ValueSet element Suggested value
title CompositionStatus Document Available
canonical url https://healthterminologies.gov.au/fhir/ValueSet/compositionstatus-document-available-1
version 1.0.0
description The CompositionStatus Document Available value set includes values that may be used to represent the status of a document that is available for electronic exchange of health information between healthcare providers, and between healthcare providers and the My Health Record system in Australia.
compose system: "http://hl7.org/fhir/composition-status"; concept: [code: "preliminary"; code: "final"; code: "amended"]

Associated FHIR Terminology Request: FTR-928

2. A new ValueSet for Composition.status containing the codes: 'final', 'amended'

ValueSet element Suggested value
title CompositionStatus Document Final
canonical url https://healthterminologies.gov.au/fhir/ValueSet/compositionstatus-document-final-1
version 1.0.0
description The CompositionStatus Document Final value set includes values that may be used to represent the status of a document that is in a final state and that is available for electronic exchange of health information between healthcare providers, and between healthcare providers and the My Health Record system in Australia.
compose system: "http://hl7.org/fhir/composition-status"; concept: [code: "final"; code: "amended"]

Associated FHIR Terminology Request: FTR-969

3. A new ValueSet for ClinicalDocument/ext:completionCode containing the codes: 'F', 'I'

ValueSet element Suggested value
title NCTIS Document Available Status Values
canonical url https://healthterminologies.gov.au/fhir/ValueSet/nctis-document-available-status-values-1
version 1.0.0
description The NCTIS Document Available Status Values value set includes values that may be used to indicate the lifecycle status of a document that is available for electronic exchange of health information between healthcare providers, and between healthcare providers and the My Health Record system in Australia.
compose system: "https://healthterminologies.gov.au/fhir/CodeSystem/nctis-document-status-values-1"; concept: [code: "F"; code: "I"]

Above value set design changed out of walkthrough 28/05 - title changed from Australian Healthcare CDA Document Available Lifecycle Status to NCTIS Document Available Status

Associated FHIR Terminology Request: FTR-974

LB-Agency commented 4 years ago

I would suggest that a new value set be created for document statuses of 'F' and 'I'. The purpose and scope of the value set has been significantly changed and no longer represents the same spectrum of statuses. It now only covers statuses of "active" or "in effect" documents.

Do the usage scenarios of CDA not cover making amendments or corrections? This could be supported with a concept addition to https://healthterminologies.gov.au/fhir/CodeSystem/nctis-document-status-values-1.

I was also found wondering what the usage scenarios were and why "entered-in-error" and "W" are outside the scope of them. Are compositions never cancelled but only superseding compositions may be sent? Thanks.

Comment by @dtr-agency OK - will go ahead with new value set, this was also the conclusion I came to.

'entered-in-error' and 'W' are completely valid values within some usage scenarios. They do not support the usage scenarios we have narrowed our profiles to supporting which at a macro-level is the exchange of electronic healthcare information between healthcare providers, and between healthcare providers and the My Health Record system for the purposes of the provision of healthcare. Storage and administration of stored content is outside of the scope of the usage scenarios for these profiles.

When a document is flagged as incorrect, possibly via a message, then the Composition could be updated to be marked as entered-in-error... it all depends on workflows in an implementation. I'm not sure of the value in sending an instance of a Composition with that status to enact that mechanism but that is entirely up to the implementation to require - it just won't satisfy our profile/templates for our usage scenarios. Alternatively the message or operation may use 'entered-in-error' or 'withdrawn' indicating a document is no longer available for sharing and the resulting change is deletion rather than Composition or ClinicalDocument being amended. Or several other scenarios of which the FHIR specification has some good descriptions. The code 'W' or its siblings are not restricted to being used in ClinicalDocument/ext:completionCode.

The CDA value set is the equivalent of 'required' only constraining is possible. I don't think amended is needed or that valuable in the Agency CDA space but should that requirement be discovered either by the Agency or proposed by a external stakeholder then we would revisit that. After amendments the document is still at a final state. How amendment, in the common use of the word, is covered is described in the documents linked in the context of this issue.

dtr-agency commented 4 years ago

ConceptMap Design Notes

4. Two new ConceptMaps to go between the 1st Composition.status ValueSet and the new ValueSet for ClinicalDocument/ext:completionCode

ConceptMap element Suggested value
title CompositionStatus Document Available to NCTIS Document Available Status Values
canonical url https://healthterminologies.gov.au/fhir/ConceptMap/compositionstatus-doc-avail-to-nctis-doc-avail-status-1
version 1.0.0
description The CompositionStatus Document Available to NCTIS Document Available Status Values concept map defines relationships from the concepts in the CompositionStatus Document Available value set to the concepts in the NCTIS Document Available Status Values value set.
sourceCanonical https://healthterminologies.gov.au/fhir/ValueSet/compositionstatus-document-available-1
targetCanonical https://healthterminologies.gov.au/fhir/ValueSet/nctis-document-available-status-values-1
group [code: preliminary; target code: I; equivalence: equivalent] [code: final; target code: F; equivalence: equivalent] [code: amended; target code: final; equivalence: subsumes]

Associated FHIR Terminology Request: FTR-984

And ConceptMap element Suggested value
title NCTIS Document Available Status Values to CompositionStatus Document Available
canonical url https://healthterminologies.gov.au/fhir/ConceptMap/nctis-doc-avail-status-to-compositionstatus-doc-avail-1
version 1.0.0
description The NCTIS Document Available Status Values to CompositionStatus Document Available concept map defines relationships from the concepts in the NCTIS Document Available Status Values value set to the concepts in the CompositionStatus Document Available value set.
sourceCanonical https://healthterminologies.gov.au/fhir/ValueSet/nctis-document-available-status-1
targetCanonical https://healthterminologies.gov.au/fhir/ValueSet/compositionstatus-document-available-1
group [code: I; target code: preliminary; equivalence: equivalent] [code: F; target code: final; equivalence: equivalent]

Associated FHIR Terminology Request: FTR-979

dtr-agency commented 4 years ago

Product owner okayed designs; passed internal review. Now for review with Terminology Analyst 01/06.

dtr-agency commented 4 years ago

Terminology Analyst review identified issues with Concept Map canonical url length and use of conventions in name field.

Name field has been removed and will be defined by terminology analyst as part of authoring service. Canonical url trimmed; may need more which will be done at analyst discretion and this ticket updated.

dtr-agency commented 4 years ago

Now accepted. Moving to publication schedule.

dtr-agency commented 4 years ago

This issue has been shifted to 'complete'; publication of the content in NCTS is pending release of NTS 2.0.

dtr-agency commented 4 years ago

To remain open until publication is confirmed.

dtr-agency commented 4 years ago

NCTS 2.0 is now live with CompositionStatus Document Available.

The other two value sets are still to be published; this issue will remain open.

davidmckillop commented 3 years ago

All value sets and concept maps have been created and are available in the NCTS. Contents have been confirmed.