2nd DSTU Draft For Comment

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4.12 Resource RiskAssessment - Content

This resource maintained by the Clinical Decision Support Work Group

An assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome.

4.12.1 Scope and Usage

This resource captures predictivd outcomes for a patient or population on the basis of source information. Examples include:

  • A prognosis statement for a particular condition
  • Risk of health outcome (heart attack, particular type of cancer) on the basis of lifestyle factors and/or family history
  • List of potential health risks based on a patient's genetic analysis
  • A prediction of outbreak infection rates within a geography based on immunization rates

4.12.2 Boundaries and Relationships

Risk assessments are a specialized type of observation. We use a specialized resource to provide a simpler mechanism to capture of a series of risks and to associate those risks with time-ranges, probabilities, etc. All risk assertions are captured at one time based on a single set of source inputs. Capture of a single risk MAY be done using the Observation class, particularly in circumstances where it's treated as a generic observation, but for consistency, all risk assessments and prognosis SHOULD be captured using RiskAssessment.

Risk assessments may be based on a variety of factors, including:

Because so many resources can potentially be used, no limit is placed on what resources can be sent in RiskAssessment.basis. However, some resources would be nonsensical for this use (e.g. MessageHeader).

4.12.3 Background and Context

Risk Assessments can be determined manually by health-care providers based on their professional expertise, by using an algorithmic scoring system or through a combination. Risk assessments can also be computed by decision support systems. OperationDefinitions may be defined by servers to generate risk assessments based on particular combinations of source resources or other inputs.

4.12.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. RiskAssessment DomainResourcePotential outcomes for a subject with likelihood
... subject Σ0..1Patient | GroupWho/what does assessment apply to?
... date Σ0..1dateTimeWhen was assessment made?
... condition Σ0..1ConditionCondition assessed
... performer Σ0..1Practitioner | DeviceWho did assessment?
... identifier Σ0..1IdentifierUnique identifier for the assessment
... method Σ0..1CodeableConceptEvaluation mechanism
... basis 0..*AnyInformation used in assessment
... prediction 0..*ElementOutcome predicted
.... outcome 1..1CodeableConceptPossible outcome for the subject
.... probability[x] ILikelihood of specified outcome
RiskAssessmentProbability (Example)
low and high must be percentages, if present
Must be <= 100
..... probabilityDecimal0..1decimal
..... probabilityRange0..1Range
..... probabilityCodeableConcept0..1CodeableConcept
.... relativeRisk 0..1decimalRelative likelihood
.... when[x] Timeframe or age range
..... whenPeriod0..1Period
..... whenRange0..1Range
.... rationale 0..1stringExplanation of prediction
... mitigation 0..1stringHow to reduce risk

UML Diagram

RiskAssessment (DomainResource)The patient or group the risk assessment applies tosubject : Reference(Patient|Group) 0..1The date (and possibly time) the risk assessment was performeddate : dateTime 0..1For assessments or prognosis specific to a particular condition, indicates the condition being assessedcondition : Reference(Condition) 0..1The provider or software application that performed the assessmentperformer : Reference(Practitioner|Device) 0..1Business identifier assigned to the risk assessmentidentifier : Identifier 0..1The algorithm, processs or mechanism used to evaluate the riskmethod : CodeableConcept 0..1Indicates the source data considered as part of the assessment (FamilyHistory, Observations, Procedures, Conditions, etc.)basis : Reference(Any) 0..*A description of the steps that might be taken to reduce the identified risk(s)mitigation : string 0..1PredictionOne of the potential outcomes for the patient (e.g. remission, death, a particular condition)outcome : CodeableConcept 1..1How likely is the outcome (in the specified timeframe)probability[x] : decimal|Range|CodeableConcept 0..1 « (The likelihood of the occurrence of a specified outcomeRiskAssessmentProbability) »Indicates the risk for this particular subject (with their specific characteristics) divided by the risk of the population in general. (Numbers greater than 1 = higher risk than the population, numbers less than 1 = lower risk.)relativeRisk : decimal 0..1Indicates the period of time or age range of the subject to which the specified probability applieswhen[x] : Period|Range 0..1Additional information explaining the basis for the predictionrationale : string 0..1Describes the expected outcome for the subjectprediction0..*

XML Template

<RiskAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <subject><!-- 0..1 Reference(Patient|Group) Who/what does assessment apply to? --></subject>
 <date value="[dateTime]"/><!-- 0..1 When was assessment made? -->
 <condition><!-- 0..1 Reference(Condition) Condition assessed --></condition>
 <performer><!-- 0..1 Reference(Practitioner|Device) Who did assessment? --></performer>
 <identifier><!-- 0..1 Identifier Unique identifier for the assessment --></identifier>
 <method><!-- 0..1 CodeableConcept Evaluation mechanism --></method>
 <basis><!-- 0..* Reference(Any) Information used in assessment --></basis>
 <prediction>  <!-- 0..* Outcome predicted -->
  <outcome><!-- 1..1 CodeableConcept Possible outcome for the subject --></outcome>
  <probability[x]><!-- 0..1 decimal|Range|CodeableConcept Likelihood of specified outcome --></probability[x]>
  <relativeRisk value="[decimal]"/><!-- 0..1 Relative likelihood -->
  <when[x]><!-- 0..1 Period|Range Timeframe or age range --></when[x]>
  <rationale value="[string]"/><!-- 0..1 Explanation of prediction -->
 </prediction>
 <mitigation value="[string]"/><!-- 0..1 How to reduce risk -->
</RiskAssessment>

JSON Template

{doco
  "resourceType" : "RiskAssessment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "subject" : { Reference(Patient|Group) }, // Who/what does assessment apply to?
  "date" : "<dateTime>", // When was assessment made?
  "condition" : { Reference(Condition) }, // Condition assessed
  "performer" : { Reference(Practitioner|Device) }, // Who did assessment?
  "identifier" : { Identifier }, // Unique identifier for the assessment
  "method" : { CodeableConcept }, // Evaluation mechanism
  "basis" : [{ Reference(Any) }], // Information used in assessment
  "prediction" : [{ // Outcome predicted
    "outcome" : { CodeableConcept }, // R! Possible outcome for the subject
    // probability[x]: Likelihood of specified outcome. One of these 3:
    "probabilityDecimal" : <decimal>,
    "probabilityRange" : { Range },
    "probabilityCodeableConcept" : { CodeableConcept },
    "relativeRisk" : <decimal>, // Relative likelihood
    // when[x]: Timeframe or age range. One of these 2:
    "whenPeriod" : { Period },
    "whenRange" : { Range },
    "rationale" : "<string>" // Explanation of prediction
  }],
  "mitigation" : "<string>" // How to reduce risk
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. RiskAssessment DomainResourcePotential outcomes for a subject with likelihood
... subject Σ0..1Patient | GroupWho/what does assessment apply to?
... date Σ0..1dateTimeWhen was assessment made?
... condition Σ0..1ConditionCondition assessed
... performer Σ0..1Practitioner | DeviceWho did assessment?
... identifier Σ0..1IdentifierUnique identifier for the assessment
... method Σ0..1CodeableConceptEvaluation mechanism
... basis 0..*AnyInformation used in assessment
... prediction 0..*ElementOutcome predicted
.... outcome 1..1CodeableConceptPossible outcome for the subject
.... probability[x] ILikelihood of specified outcome
RiskAssessmentProbability (Example)
low and high must be percentages, if present
Must be <= 100
..... probabilityDecimal0..1decimal
..... probabilityRange0..1Range
..... probabilityCodeableConcept0..1CodeableConcept
.... relativeRisk 0..1decimalRelative likelihood
.... when[x] Timeframe or age range
..... whenPeriod0..1Period
..... whenRange0..1Range
.... rationale 0..1stringExplanation of prediction
... mitigation 0..1stringHow to reduce risk

UML Diagram

RiskAssessment (DomainResource)The patient or group the risk assessment applies tosubject : Reference(Patient|Group) 0..1The date (and possibly time) the risk assessment was performeddate : dateTime 0..1For assessments or prognosis specific to a particular condition, indicates the condition being assessedcondition : Reference(Condition) 0..1The provider or software application that performed the assessmentperformer : Reference(Practitioner|Device) 0..1Business identifier assigned to the risk assessmentidentifier : Identifier 0..1The algorithm, processs or mechanism used to evaluate the riskmethod : CodeableConcept 0..1Indicates the source data considered as part of the assessment (FamilyHistory, Observations, Procedures, Conditions, etc.)basis : Reference(Any) 0..*A description of the steps that might be taken to reduce the identified risk(s)mitigation : string 0..1PredictionOne of the potential outcomes for the patient (e.g. remission, death, a particular condition)outcome : CodeableConcept 1..1How likely is the outcome (in the specified timeframe)probability[x] : decimal|Range|CodeableConcept 0..1 « (The likelihood of the occurrence of a specified outcomeRiskAssessmentProbability) »Indicates the risk for this particular subject (with their specific characteristics) divided by the risk of the population in general. (Numbers greater than 1 = higher risk than the population, numbers less than 1 = lower risk.)relativeRisk : decimal 0..1Indicates the period of time or age range of the subject to which the specified probability applieswhen[x] : Period|Range 0..1Additional information explaining the basis for the predictionrationale : string 0..1Describes the expected outcome for the subjectprediction0..*

XML Template

<RiskAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <subject><!-- 0..1 Reference(Patient|Group) Who/what does assessment apply to? --></subject>
 <date value="[dateTime]"/><!-- 0..1 When was assessment made? -->
 <condition><!-- 0..1 Reference(Condition) Condition assessed --></condition>
 <performer><!-- 0..1 Reference(Practitioner|Device) Who did assessment? --></performer>
 <identifier><!-- 0..1 Identifier Unique identifier for the assessment --></identifier>
 <method><!-- 0..1 CodeableConcept Evaluation mechanism --></method>
 <basis><!-- 0..* Reference(Any) Information used in assessment --></basis>
 <prediction>  <!-- 0..* Outcome predicted -->
  <outcome><!-- 1..1 CodeableConcept Possible outcome for the subject --></outcome>
  <probability[x]><!-- 0..1 decimal|Range|CodeableConcept Likelihood of specified outcome --></probability[x]>
  <relativeRisk value="[decimal]"/><!-- 0..1 Relative likelihood -->
  <when[x]><!-- 0..1 Period|Range Timeframe or age range --></when[x]>
  <rationale value="[string]"/><!-- 0..1 Explanation of prediction -->
 </prediction>
 <mitigation value="[string]"/><!-- 0..1 How to reduce risk -->
</RiskAssessment>

JSON Template

{doco
  "resourceType" : "RiskAssessment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "subject" : { Reference(Patient|Group) }, // Who/what does assessment apply to?
  "date" : "<dateTime>", // When was assessment made?
  "condition" : { Reference(Condition) }, // Condition assessed
  "performer" : { Reference(Practitioner|Device) }, // Who did assessment?
  "identifier" : { Identifier }, // Unique identifier for the assessment
  "method" : { CodeableConcept }, // Evaluation mechanism
  "basis" : [{ Reference(Any) }], // Information used in assessment
  "prediction" : [{ // Outcome predicted
    "outcome" : { CodeableConcept }, // R! Possible outcome for the subject
    // probability[x]: Likelihood of specified outcome. One of these 3:
    "probabilityDecimal" : <decimal>,
    "probabilityRange" : { Range },
    "probabilityCodeableConcept" : { CodeableConcept },
    "relativeRisk" : <decimal>, // Relative likelihood
    // when[x]: Timeframe or age range. One of these 2:
    "whenPeriod" : { Period },
    "whenRange" : { Range },
    "rationale" : "<string>" // Explanation of prediction
  }],
  "mitigation" : "<string>" // How to reduce risk
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

4.12.4.1 Terminology Bindings

PathDefinitionTypeReference
RiskAssessment.method The mechanism or algorithm used to make the assessment. E.g. TIMI, PRISM, Cardiff Type 2 diabetes, etc.UnknownNo details provided yet
RiskAssessment.prediction.outcome The condition or other outcome. E.g. death, remission, amputation, infection, etc.UnknownNo details provided yet
RiskAssessment.prediction.probability[x] The likelihood of the occurrence of a specified outcomeExamplehttp://hl7.org/fhir/vs/risk-probability

4.12.4.2 Constraints

  • ras-1: On RiskAssessment.prediction.probability[x]: low and high must be percentages, if present (xpath on f:RiskAssessment/f:prediction/f:probability[x]: (not(f:low) or f:low[f:code/@value='%' and f:system/@value='http://unitsofmeasure.org']) and (not(f:high) or f:high[f:code/@value='%' and f:system/@value='http://unitsofmeasure.org']))
  • ras-2: On RiskAssessment.prediction.probability[x]: Must be <= 100 (xpath on f:RiskAssessment/f:prediction/f:probability[x]: @value <= 100)

4.12.5 Open Issues

  • Is there an existing code system we can use as a recommended value set for risk probabilties?
  • Should risk assessments apply to devices, locations or any other resources (as part of the 80%)?
  • Is identification of risk assessment method part of the 80%?
  • Is relative risk in the 80%?

4.12.6 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
conditionreferenceCondition assessedRiskAssessment.condition
(Condition)
datedateWhen was assessment made?RiskAssessment.date
identifiertokenUnique identifier for the assessmentRiskAssessment.identifier
methodtokenEvaluation mechanismRiskAssessment.method
patientreferenceWho/what does assessment apply to?RiskAssessment.subject
(Patient)
performerreferenceWho did assessment?RiskAssessment.performer
(Device, Practitioner)
subjectreferenceWho/what does assessment apply to?RiskAssessment.subject
(Patient, Group)