This page is part of the US Core (v3.0.1: STU3 Ballot 3) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions 
Basic Provenance Guidance
This section provides implementers with important definitions to create and share the Provenance Resource.
Basic Provenance
The FHIR Provenance Resource provides a foundation for assessing authenticity, enabling trust, and allowing reproducibility. It isn’t scoped to a specific use case, nor limits the number of Provenance records associated with a Resource. The basic guidance here, and in the US Core Provenance Profile focuses on a key subset of elements, the ‘last hop’, and specific use cases. The guidance here doesn’t preclude more advanced use cases or additional elements.
Full Provenance of a Resource requires details from the original creator of a Resource and all intermediary actors that updated the Resource. Members of the Argonaut community and the HL7 security working group discussed the current sharing approaches, and display to end user, and agreed the most important information is the last organization making a meaningful clinic update to the data, and the prior system providing the data, the ‘last hop’. Participants didn’t dispute the potential need to recreate the full chain, but didn’t see this as relevant to the immediate end-user.
Key Provenance Elements
The guidance for Provenance in US Core focuses on 6 key elements: Timestamp, the Target Resource, Author, Author Organization, Transmitter, and Transmitter Organization. The timestamp is the date and time the author created, updated, or deleted the data. The target is the Resource the Provenance record supports. The Author represents the person(s) responsible for the information. The Author Organization represents the organization the author is associated when they created, updated, or deleted the data. The Transmitter represents the system responsible for transmitting the information. The Transmitter Organization represents the organization responsible for the transmission.
Key Provenance elements:
| Element | Required | Must Support | Optional | FHIR Element |
|---|---|---|---|---|
| Target | Resource Provenance record supports |
Provenance.target | ||
| Timestamp | Date | Time with timezone offset | Provenance.recorded | |
| Author | Name Identifier |
NPI recommended, additional identifiers allowed | Provenance.agent.who | |
| Author Organization | Name Identifier |
NPI recommended, additional identifiers allowed | Provenance.agent.onBehalfOf | |
| Transmitter | Name Identifier |
NPI recommended, additional identifiers allowed | Provenance.agent.who | |
| Transmitter Organization | Name Identifier |
NPI recommended, additional identifiers allowed | Provenance.agent.onBehalfOf |
Use Cases
The HL7 Basic Provenance Informative implementation guide outlines four use cases: Fax, Health Information Exchange (HIE) redistribution, HIE transformation, and Clinical Information Reconciliation and Incorporation (CIRI). While these use cases may have FHIR implications in the future, CIRI and HIE are the key use cases and are covered in detail here.
Clinical Information Reconciliation and Incorporation
Clinical Information Reconciliation and Incorporation (CIRI) is a process where a user reviews and updates, or accepts, information into their system. The information could come from a Health Information Exchange (HIE), a 3rd-party FHIR server, or a patient providing information. Figure 1 represents information being provided from two different sources, Good Health organization and Sunshine Health Organization. Dr. Reconciled reviews the information in Figure 2, updates the reaction to hives, and stores into the Future Health Organization system. When a mobile app requests the information they receive Dr. Reconciled as the Author and Future Health as the organization.
The Figure below represents information from two different organizations to a clinician for reconciliation:
Dr. Reconciled is the latest author after updating the reaction on 5/15/2019 and accepting to the local data store. The acceptance of the information is them taking over the responsibility.
GET /AllergyIntolerance?patient=[ID]&us-core-includeprovenance
Good Health Organization Provenance
Request:
Get “all allergies” for a patient and all corresponding Provenance records.
GET [base]/AllergyIntolerance?patient=12345&us-core-includeprovenance
Response:
A Server returns a search Bundle resource containing all the Allergies for the patient and corresponding Provenance records.
HTTP/1.1 200 OK
[other headers]
{
"resourceType": "Bundle",
"id": "c887e62f-6166-419f-8268-b5ecd6c7b901",
"meta": {
"lastUpdated": "2019-07-09T18:49:01.235+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "http://hapi.fhir.org/baseR4/AllergyIntolerance??patient=Examples&us-core-includeprovenance"
}
],
"entry": [
{
"fullUrl": "http://hapi.fhir.org/baseR4/AllergyIntolerance/79613",
"resource": {
"resourceType": "AllergyIntolerance",
"id": "79613",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"
]
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code": "active",
"display": "Active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "762952008",
"display": "Peanuts"
}
],
"text": "Peanuts"
},
"category": [
"medication"
],
"criticality": "high",
"patient": {
"reference": "Patient/example"
},
"onsetDateTime": "2018-01",
"reaction": [
{
"manifestation": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "247472004",
"display": "Hives"
}
]
}
],
"onset": "2018-01"
}
]
},
"search": {
"mode": "match"
}
},
{
"fullUrl": "http://hapi.fhir.org/baseR4/Provenance/79614",
"resource": {
"resourceType": "Provenance",
"id": "79614",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-provenance"
]
},
"target": [
{
"reference": "AllergyIntolerance/79613"
}
],
"recorded": "2018-02T15:26:23.217+00:00",
"agent": [
{
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type",
"code": "author",
"display": "Author"
}
]
}
],
"who": {
"reference": "Practitioner/Dr-Jones-12345"
},
"onBehalfOf": {
"reference": "Organization/good-health-54321"
}
}
]},
"search": {
"mode": "include"
}
}
] }
Sunshine Health Organization Provenance
Request:
Get “all allergies” for a patient and all corresponding Provenance records.
GET [base]/AllergyIntolerance?patient=1234599&us-core-includeprovenance
Response:
A Server returns a search Bundle resource containing all the Allergies for the patient and corresponding Provenance records.
HTTP/1.1 200 OK
[other headers]
{
"resourceType": "Bundle",
"id": "c887e62f-6166-419f-8268-b5ecd6c7b901",
"meta": {
"lastUpdated": "2019-07-09T18:49:01.235+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "http://hapi.fhir.org/baseR4/AllergyIntolerance??patient=Examples99&us-core-includeprovenance"
}
],
"entry": [
{
"fullUrl": "http://hapi.fhir.org/baseR4/AllergyIntolerance/7961399",
"resource": {
"resourceType": "AllergyIntolerance",
"id": "7961399",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"
]
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code": "active",
"display": "Active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "762952008",
"display": "Peanuts"
}
],
"text": "Peanuts"
},
"category": [
"medication"
],
"criticality": "high",
"patient": {
"reference": "Patient/example"
},
"onsetDateTime": "2017-09",
"reaction": [
{
"manifestation": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"code": "UNK",
"display": "Unknown"
}
]
}
],
"onset": "2017-09"
}
]
},
"search": {
"mode": "match"
}
},
{
"fullUrl": "http://hapi.fhir.org/baseR4/Provenance/7961499",
"resource": {
"resourceType": "Provenance",
"id": "7961499",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-provenance"
]
},
"target": [
{
"reference": "AllergyIntolerance/7961399"
}
],
"recorded": "2017-09T15:26:23.217+00:00",
"agent": [
{
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type",
"code": "author",
"display": "Author"
}
]
}
],
"who": {
"reference": "Practitioner/Dr-Smith-1234599"
},
"onBehalfOf": {
"reference": "Organization/sunshine-health-5432199"
}
}
]},
"search": {
"mode": "include"
}
}
] }
After reconciliation, the Future Health Organization Provenance contains the latest information.
Request:
Get “all allergies” for a patient and all corresponding Provenance records.
GET [base]/AllergyIntolerance?patient=123459988&us-core-includeprovenance
Response:
A Server returns a search Bundle resource containing all the Allergies for the patient and corresponding Provenance records.
HTTP/1.1 200 OK
[other headers]
{
"resourceType": "Bundle",
"id": "94d5d5ac-6645-41dc-8282-1870b71e840a",
"meta": {
"lastUpdated": "2019-07-20T18:49:01.235+00:00"
},
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "http://hapi.fhir.org/baseR4/AllergyIntolerance?patient=Examples9988&us-core-includeprovenance"
}
],
"entry": [
{
"fullUrl": "http://hapi.fhir.org/baseR4/AllergyIntolerance/796139988",
"resource": {
"resourceType": "AllergyIntolerance",
"id": "796139988",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"
]
},
"clinicalStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
"code": "active",
"display": "Active"
}
]
},
"verificationStatus": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
"code": "confirmed",
"display": "Confirmed"
}
]
},
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "762952008",
"display": "Peanuts"
}
],
"text": "Peanuts"
},
"category": [
"medication"
],
"criticality": "high",
"patient": {
"reference": "Patient/example"
},
"onsetDateTime": "2017-09",
"reaction": [
{
"manifestation": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "247472004",
"display": "Hives"
}
]
}
],
"onset": "2017-09"
}
]
},
"search": {
"mode": "match"
}
},
{
"fullUrl": "http://hapi.fhir.org/baseR4/Provenance/796149988",
"resource": {
"resourceType": "Provenance",
"id": "796149988",
"meta": {
"versionId": "1",
"lastUpdated": "2019-07-09T15:26:23.217+00:00",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-provenance"
]
},
"target": [
{
"reference": "AllergyIntolerance/796139988"
}
],
"recorded": "2019-05-15T15:26:23.217+00:00",
"agent": [
{
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/provenance-participant-type",
"code": "author",
"display": "Author"
}
]
}
],
"who": {
"reference": "Practitioner/dr-reconciled-123459988"
},
"onBehalfOf": {
"reference": "Organization/future-health-543219988"
}
}
]},
"search": {
"mode": "include"
}
}
] }
Accepting information from a single site
The Figure below represents information after a provider accepted information from a single site:
Dr. Accepted is the latest author after verifying the problem on 5/2018 and accepting the problem data into their local data store, since it went through an interactive reconciliation process. This type of authorship change is only relevant for data fit for reconciliation, such as medications, allergies, problems. If Dr. Accepted had saved other clinical content into his EHR that aren’t reconciled but simply stored, such as clinical notes, that content must retain its original author.
HIE Redistribution
A Health Information Exchange (HIE) is an organization and a technology to facilitate exchange from one to many partners. In certain HIE scenarios they only redistribute information, while in others they store, transform, and redistribute information. The HIE must keep fidelity of the clinical content, (original author, author organization, and timestamp). The HIE must keep track of who sent them the information for auditing, however, they are not required to include the original transmitter when redistributing content.
Since no clinical content is changed in the HIE redistribution the best scenario is a single Provenance Record with:
- Provenance.agent.type = author
- Provenance.agent.who set to the practitioner who authored the content (i.e. not the HIE)
- Provenance.agent.onBehalfOf set to the organization that author acted on behalf of before sharing with the HIE
- Provenance.agent.type = transmitter
- Provenance.agent.who set to the HIE organization
The timestamp and pointer (i.e. target) to the appropriate Resource is required in all cases and must be included. This IG would note these as SHALL constraints if systems always had the Author and Author Organizations available. Participants in the development of this guide reported Author information provided to HIEs is inconsistent and unreliable.
HIE Transformation
Different from Use Case 3 - HIE Redistribution, Use Case 4 includes transformation of data. Information is received (e.g. v2 lab, other CDs) and transformed by a HIE, stored, and then passed in a new format (e.g. CCD). Source data is not manipulated beyond transforming into a new format. Transformation of data from one format to another does not change the authorship of the information. The HIE is only the author/author organization if they produce and include new information. For example, if a v2 lab message is received and stored into the HIE, and then subsequently included in a CDA document, the author/author organization is the lab that sent the original message. The addition of terminology translations, or additional identifiers, should not influence the authorship of the information. Alternatively, the HIE is the author/author organization if they created new information, such as calculation of a quality measure score. If specific clinical elements were included to support the quality calculation, they would reference their original author/author organization
In figure 4, each different stripe in the folder represents a different Resource. For the 3 items where the information is carried from the original system the best scenario is a single Provenance Record for each Resource with:
- Provenance.agent.type = author
- Provenance.agent.who set to the practitioner who authored the content (i.e. not the HIE)
- Provenance.agent.onBehalfOf set to the organization that author acted on behalf of before sharing with the HIE
- Provenance.agent.type = transmitter
- Provenance.agent.who set to the HIE organization
This matches the requirements of HIE Redistribution.
For the new content, the HIE is the Author so the following is recommenced:
- Provenance.agent.type = author
- Provenance.agent.onBehalfOf set to the HIE organization
- Provenance.agent.type = transmitter
- Provenance.agent.who set to the HIE organization
Development of us-core-includeprovenance parameter
The original design in this guide required support for the _revinclude parameter (see Including other resources in result) to retrieve a Provenance Record. After discussing this approach at length with the Argonaut community, and client developers, the US Core guidance shifted to the custom parameter us-core-includeprovenance.
Functionally, the searches
GET /AllergyIntolerance?patient=[ID]&_revinclude=Provenance:target and GET /AllergyIntolerance?patient=[ID]&us-core-includeprovenance are equivalent.
Implementers found the name _revinclude non-intuitive, and were concerned clients would assume if FHIR servers supported this for Provenance, they would be adding support for other use cases. None of the servers that participated in the development of this guide have _revinclude in their current development roadmap.
