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4.35 Resource Questionnaire - Content

Patient Care Work Group

Maturity Level: 2

Compartments: Not linked to any defined compartments

A structured set of questions intended to guide the collection of answers. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the underlying questions.

This resource is referenced by questionnaireresponse

4.35.4 Resource Content

 

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

4.35.4.1 Terminology Bindings

Path	Definition	Type	Reference
Questionnaire.status	Lifecycle status of the questionnaire.	Required	QuestionnaireStatus
Questionnaire.concept Questionnaire.item.concept	Codes for questionnaires, groups and individual questions	Example	Questionnaire Question Codes
Questionnaire.subjectType	One of the resource types defined as part of FHIR.	Required	http://hl7.org/fhir/valueset/resource-typesResourceType
Questionnaire.item.type	Distinguishes groups from questions and display text and indicates data type for questions	Required	QuestionnaireItemType
Questionnaire.item.option	Allowed values to answer questions.	Example	Questionnaire Answer Codes

4.35.4.2 Constraints

• que-1: On Questionnaire.item: Group items must have nested items, display items cannot have nested items (xpath on f:Questionnaire/f:item: not((f:type/@value='group' and not(f:item)) or (f:type/@value='display' and f:item)))
• que-2: The link ids for groups and questions must be unique within the questionnaire (xpath: count(descendant::f:linkId/@value)=count(distinct-values(descendant::f:linkId/@value)))
• que-3: On Questionnaire.item: Display items cannot have a "concept" asserted (xpath on f:Questionnaire/f:item: not(f:type/@value='display' and f:concept))
• que-4: On Questionnaire.item: A question cannot have both option and options (xpath on f:Questionnaire/f:item: not(f:options and f:option))
• que-5: On Questionnaire.item: Only 'choice' items can have options (xpath on f:Questionnaire/f:item: f:type/@value=('choice','open-choice') or not(f:option or f:options))
• que-6: On Questionnaire.item: Required and repeat aren't permitted for display items (xpath on f:Questionnaire/f:item: not(f:type/@value='display' and (f:required or f:repeats)))

4.35.5 Notes:

• Questionnaires may be used to represent predefined forms or panels, referenced using items of type "group"
• Questions may be nested. The Questionnaire resource supports nested items beneath both items of type "group" (which doesn't capture an answer of its own) as well as beneath questions
• Groups and Questions may have linkIds allowing groups and question answers captured in a QuestionnaireResponse to be associated with their corresponding group or question.
• Questionnaire allows for flexible naming and structuring of its contents to reflect the flexible and varying nature of forms and questionnaires. It explicitly does not try to standardize or streamline exchange of its contents outside its context of use, although exchanging partners may further constrain its structure and flexibility using profiles to define standardized, reusable forms.
• Because of the lack of explicit support for Questionnaires in HL7 v3 , CDA Documents frequently used named sections with Observations to model Questionnaires. Such use cases should now use the Questionnaire Resource instead.
• The order of questions within groups, groups within groups and groups within questions is relevant and must be retained for display and capture.
• Display items allow the inclusion of instructions, background information and similar content within a questionnaire.

4.35.5.1 Using Questionnaires versus using Resources

There is considerable overlap between the information covered by Questionnaires and other Resources (especially FamilyMemberHistory, MedicationStatement, Observation, Procedure, etc.): Questionnaire's flexible structure can easily be misused to capture any data, even data that should be captured as separate Resources. The choice between using Questionnaires or separate Resources may be dictated by the procedure of collection and recording; e.g. if the data is captured as a physician-agreed (electronic) form, it might be impossible or undesirable to distill separate resources from it and capturing the data in a Questionnaire would be most appropriate.

However, data captured only in Questionnaires can be difficult to query after-the-fact. Queries against other Resources will not return data captured only in Questionnaires, and querying against Questionnaires directly may not find all desired data, depending on how the questions may have been phrased or encoded over time or by different clinicians. Moreover, interoperability of such Questionnaires is limited, as interpretation of its contents is only known to the circle of parties that were involved in its definition: encoding data from such Questionnaires using other, more specific, Resources increases the ability and consistency with which it can be understood and queried.

It is entirely possible for data to exist in both QuestionnaireResponse and in other resources. For example, data may be captured in QuestionnaireResponse as part of an intake questionnaire. That data may then be propagated into the Patient resource (demographics), FamilyMemberHistory, AllergyIntolerance, MedicationStatement and Observation resources to allow the data to be queried and analyzed. The original QuestionnaireResponse instance can be retained for traceability purposes. If desired, a Provenance resource can be used to identify the Questionnaire as the data source for the other resources. For example, if a questionnaire question asks "what is your weight", that can then result in the creation of an Observation with the appropriate Observation.code and the specified answer as the Observation.valueQuantity.

4.35.5.2 Structure of the Questionnaire

A Questionnaire is built out of two components:

• The main component is Questionnaire, which holds information about the Questionnaire, like the identifier, publisher, date authored, title, etc. The Questionnaire contains zero or more items which define the content of the questionnaire. (Zero items allows for the possibility of narrative-only questionnaires, though obviously these provide little computable information.)
• Items have one of three sub-types, distinguished by the type element:
  • display items convey text to be rendered on the form that won't capture data and which won't contain nested items. This might include copyright or authorship information, instructions or other background.
  • group items organize content of the questionnaire into sections, sub-sections, etc. Groups don't have answers associated with them directly, but generally contain child 'question' items which do.
  • question items ask a specific question to which an answer may be given. There isn't a single type for question items. Instead, the type conveys the data type of the answer for the question. If an item isn't a 'display' or a 'group', then it's a question. and actual "question" information which allows a particular type of answer to be gathered (and which may also have nested items). Questions may also have nested content - groups and/or other questions. This way, one can model "panels" of questions which would only be relevant (and thus would only be displayed) depending on the answers of a parent question; e.g. a question "Did the patient receive treatment in the past six months?" would contain a nested group of questions asking for further details about the treatment. See an example from the Australian New South Wales blue book

Specific controls on dynamic display of groups, questions, etc. based on the answers to other questions is outside the scope of the base resource and are handled using extensions.

4.35.5.3 Identifiers within Questionnaire

There are three different "identifying" elements within Questionnaire: identifier, id and linkId. Each serves very distinct purposes:

• identifier is used to reference the overall questionnaire in business terms. It is the number printed across the top of the form or listed beside the form when making a choice between alternate forms.
• The id attribute supported on each element is used for references within a resource, for example linking narrative to discrete elements. Ids are not generally displayed to end users
• The linkId element on questions and groups establishes a link between elements in a QuestionnaireAnsers and their definition inside a Questionnaire. This is the only way to link between the groups and questions in a Questionnaire and QuestionnaireResponse. These are also not displayed to end users

4.35.5.4 Question Definitions

Questionnaires can be crafted using any questions the author can conceive phrased in whatever manner is appropriate or convenient. However, standardization of questions and the constraints enforced on the accompanying answers increases the ability to compare data gathered across questionnaires. There are two mechanisms defined in the specification for linking a Question (or Group) to a standardized definition:

• The concept element on both Group and Question allows an individual question, a group of questions or even the questionnaire as a whole to be associated with a pre-defined terminology of questions and question groups such as LOINC
• The deReference extension allows a question or group to be associated with the DataElement (DE) resource that formally defines the data element.

Linking to formal definitions of a question allows data captured by distinct questionnaires to be compared. If systems have the necessary mappings to the formal definition, linkages to formal definitions may also be used to automatically pre-populate or extract data from a corresponding QuestionnaireResponse resource.

NOTE: Even if standard question definitions are referenced using concept or the deReference extension, information such as the question text, data type and value set SHOULD still be declared for the question. Systems processing the questionnaire may not have access to or support the ability to look up the question definitions from external sources. If the information is not included in-line within the questionnaire, other systems may not be able to to render or use the Questionnaire.

If an external reference (concept or deReference extension) is included along with question information such as question text, data type or value set, it is expected that the content for the question and the referenced definition would be in alignment. However, FHIR does not dictate what degree of alignment is required; e.g. Does the question text need to match exactly? Is it legitimate for a question to constrain the allowed value set of possible answers? These rules will need to be established within implementation environments.

4.35.5.5 Question types

The codes for the data type for each question are slightly different than the data types allowed in the QuestionnaireResponse resource. Where the names are the same (ignoring case), the "answer" must use the specified type. Where the names are different, the mappings are as follows:

Questionnaire AnswerFormat code	QuestionnaireResponse data type
text	string
url	uri
choice	Coding
open-choice	Coding

4.35.5.6 Permitted values for questions

Many questionnaires place constraints on the allowed list of values for a given question. FHIR supports this notion through the item.choices or the item.choice element.

The "choice" mechanism is simplest - all options are listed in-line with the question. Maintenance of the set of permitted question answers involves maintenance of the questionnaire itself.

The "choices" mechanism is more sophisticated. Rather than listing the choices directly, the choices element points to a ValueSet resource. This approach adds complexity for questionnaires having a simple list of strings as choices for a question, but provides several benefits:

• Questionnaires that reference codes from externally defined code systems have a means of doing so
• Answer sets can be shared across questions (and there are many questionnaires where this capability is useful)
• The full capability of value sets can be brought into play, including the ability to use ConceptMap to link and translate from questionnaire-specific codes to other codes, the use of multiple display names (e.g. different languages), the ability to use coded ordinals, the ability to allow choices from larger value sets (e.g. "all SNOMED CT procedure codes")
• etc.

In many cases, the set of code choices will be specific to a given questionnaire and should be maintained as part of the questionnaire. In this case, the referenced ValueSet can be included as a contained resource. All contained ValueSets are listed together and then are referenced by the individual questions as necessary. Alternatively, the "choices" element can reference the value set in a version-specific manner. This ensures that the Questionnaire will not adopt a new version of the referenced value set without revising the Questionnaire to point to that new version - putting the author of the Questionnaire in control of any changes.

4.35.5.7 Useful Value Sets

Many questions have a set of possible codes for their answer. These value sets may be useful to help, and when referenced by full URL, do not need to be provided as part of the questionnaire:

• Yes | No | Don't Know: http://hl7.org/fhir/ValueSet/yesnodontknow

4.35.5.8 Questions with multiple answer types

In some questionnaires, it may be possible to respond to a question with multiple types of answers. For example, capturing a coded answer plus free text, capturing a coded value plus a numeric priority, etc. In FHIR, this is handled through nested questions. Each question has a single data type. However, each question can have nested child questions. These nested child questions can have text (e.g. "Please specify") or can have no text at all if the appropriate guidance is provided by the parent question or group.

4.35.5.9 Questionnaires with Math

While not defined (yet) as part of the FHIR specification, extensions may be defined to perform mathematical functions on questionnaire responses. For example, tabulating scores. One extension that is defined that may be useful in this process is the Ordinal extension. This allows a numeric value to be associated with a coded data element. There are two extensions defined - one for defining the numeric weighting of a code defined in a value set - valueset-ordinalValue and the other is a code that can appear within a Coding itself - iso21090-CO-value.

4.35.6 Search Parameters

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

Name	Type	Description	Paths
code	token	A code that corresponds to the questionnaire or one of its groups	Questionnaire.item.concept
date	date	When the questionnaire was last changed	Questionnaire.date
identifier	token	An identifier for the questionnaire	Questionnaire.identifier
publisher	string	The author of the questionnaire	Questionnaire.publisher
status	token	The status of the questionnaire	Questionnaire.status
title	string	All or part of the name of the questionnaire	Questionnaire.title
version	string	The business version of the questionnaire	Questionnaire.version