HL7.FHIR.US.DAVINCI-DTR\Requesting Additional Information from the User

This page is part of the Documentation Templates and Rules (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Requesting Additional Information from the User

Questionnaire Rendering
Provider Attestation
Recording Responses

While the goal of DTR is to automatically gather all of the necessary information to satisfy payer rules and documentation requirements without interrupting the user, this is not possible in all cases. When the execution of Clinical Quality Language (CQL) is unable to obtain the required data, it is necessary to prompt the user for more input.

Questionnaire Rendering

The DTR process will need to collect information from the user for items in the Questionnaire where the following conditions are met:

The cqf-expression for the item evaluates to null
If the item has an enableWhen property, the conditions for the statements: operator and answer[x] evaluate to true.

Payers should note that the sequencing of item elements in a Questionnaire resource is considered to be relevant by the FHIR specification. The DTR process SHALL prompt users for items in the sequence that they appear in the Questionnaire resource. Payers should also take note of the sequence of items when making use of the enableWhen property. An item SHOULD only use enableWhen if it can obtain an answer from a previously answered question.

When items meet the conditions stated above, they SHALL be presented to the user for their input.

Structured Data Capture

Payers may have requirements on how questions are presented to users. To allow for this, payers MAY supply Questionnaire resources that conform to the Advanced Rendering Questionnaire Profile as defined in Structure Data Capture.

The purpose of this extension is to indicate that it is not SAFE to render the form if the styles indicated in the Questionnaire are not followed. If the system is not capable of rendering the form as the Questionnaire dictates, then it cannot display the form. Note the use of this flag should be extremely rare in DTR.

If the rendering-styleSensitive extension property is not present or false the DTR process SHOULD use rendering-style and rendering-xhtml properties.

Rendering Questionnaire items without specified styles

Payers are not required to provide Questionnaires that conform to the Advanced Rendering Questionnaire Profile. When a Questionnaire is provided that does not conform to this profile, it is at the discretion of the DTR process to choose a reasonable presentation of the questions that require user input. The DTR process SHALL use the appropriate input mechanism depending on the item.type. When working with a FHIR R4 Questionnaire, the DTR process SHALL support item.answerValueSet, item.answerOption, and item.initial if provided.

Rendering multiple items

This IG does not place any requirements on the DTR process to display multiple Questionnaire.items to a user at a time or only a single item. Implementers should decide which method of displaying questions makes the most sense within the end user workflow. We encourage Questionnaire designs that minimize the number of questions that are necessary to view/complete (i.e., if an answer obviates the need to complete a section, then the section should not appear for completion, unless local workflow(s) determine a need for editing or review).

Provider Attestation

There may be cases where the CQL provided by a payer was unable to locate information for a patient that is present in the Electronic Health Record (EHR) system. This may be due to the information existing in unstructured notes or in locations the CQL did not expect. To reduce the burden on the users of the application, DTR provides a mechanism for the user to attest that the information exists in the patient’s record, without specifying the exact value or location of the information. This will not require the user to reenter the missing information.

The DTR process SHALL include a mechanism to allow a user to attest the answer to the presented question exists in the patient’s record. This mechanism MAY be an HTML input element with the type set to button or it may be an a element. The behavior of these elements SHALL be to record the user’s attestation that the information is present in the patient’s record.

When a user provides an attestation, the DTR process SHALL record that in the corresponding QuestionnaireResponse.item. In this case, the DTR process SHALL create an answer property on the item. The answer SHALL have a valueCoding that is set to the SNOMED CT code 410515003, known present. The item will also have an author extension property which will reference the fhirUser provided to the DTR process.

If an answer is attested, the user should provide evidence that the attested value exists in the patient’s record by including an attachment or the equivalent with the QuestionnaireResponse.

If information is privacy restricted, the information SHOULD be treated as if it does not exist. The provider SHOULD ask the patient if they want to share the information with the payer.

Recording Responses

The DTR process SHALL take input from the user and record the provided information. As with provider attestation, the DTR process SHALL record that in the corresponding QuestionnaireResponse.item. In this case, the DTR process SHALL create an answer property on the item. The answer SHALL have an appropriate value[x] depending on the corresponding type in the Questionnaire.item. Again, similar to attestations, the item will have an author extension property which will reference the fhirUser provided to the DTR process.

QuestionnaireResponse

The DTR process SHALL create a QuestionnaireResponse resource based on all of the information collected. Given the following JSON fragment representing a Questionnaire.item:

{
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
      "valueExpression": {
        "language": "text/cql",
        "expression": "Age"
      }
    }
  ],
  "linkId": "age",
  "code": [
    {
      "system": "http://loinc.org",
      "code": "30525-0"
    }
  ],
  "text": "What is the patient's age?",
  "type": "quantity"
}

The following QuestionnaireResponse.item JSON fragment would be created assuming that the patient’s age is 65 years old and that this information was gathered through CQL execution.

{
  "linkId": "age",
  "answer": {
    "valueQuantity": {"value": 65, "unit": "a", "system": "http://unitsofmeasure.org"}
  }
}

If the value was supplied by the user, the author extension property will be set. The following QuestionnaireResponse.item JSON fragment provides an example of this:

{
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
      "valueReference": {
        "reference": "http://exampleprovider.org/fhir/Practitioner/1234"
      }
    }
  ],
  "linkId": "age",
  "answer": {
    "valueQuantity": {"value": 65, "unit": "a", "system": "http://unitsofmeasure.org"}
  }
}

Finally, if the user did not supply a value, but provided an attestation that the information exists in the patient’s record, it would be represented by the following QuestionnaireResponse.item JSON fragment:

{
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/questionnaireresponse-author",
      "valueReference": {
        "reference": "http://exampleprovider.org/fhir/Practitioner/1234"
      }
    }
  ],
  "linkId": "age",
  "answer": {
    "valueCoding": {
      "system": "http://snomed.info/sct", "code": "410515003"
    }
  }
}

Separating user provided information from CQL retrieved information

For information systems processing a QuestionnnaireResponse generated by the DTR process SHALL populate the QuestionnaireResponse.item with the author extension property if the item was created by user input. If the author property is not present, then the information was gathered through the execution of CQL.