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8.1 Resource Patient - Content

Patient Administration Work Group

Maturity Level: 5

Trial Use

Compartments: Patient, Practitioner, RelatedPerson

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

This resource is referenced by Account, AdverseEvent, AllergyIntolerance, Appointment, AppointmentResponse, AuditEvent, Basic, BodySite, CarePlan, CareTeam, ChargeItem, Claim, ClaimResponse, ClinicalImpression, Communication, CommunicationRequest, Composition, Condition, Consent, Contract, Coverage, DetectedIssue, Device, DeviceRequest, DeviceUseStatement, DiagnosticReport, DocumentManifest, DocumentReference, EligibilityRequest, Encounter, EnrollmentRequest, EpisodeOfCare, ExplanationOfBenefit, FamilyMemberHistory, Flag, Goal, Group, GuidanceResponse, ImagingManifest, ImagingStudy, Immunization, ImmunizationRecommendation, List, MeasureReport, Media, MedicationAdministration, MedicationDispense, MedicationRequest, MedicationStatement, NutritionOrder, Observation, Person, Procedure, ProcedureRequest, Provenance, QuestionnaireResponse, ReferralRequest, RelatedPerson, RequestGroup, ResearchSubject, RiskAssessment, Schedule, Sequence, Specimen, SupplyDelivery, SupplyRequest, Task and VisionPrescription

8.1.2 Resource Content

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

8.1.2.1 Terminology Bindings

Path	Definition	Type	Reference
Patient.gender Patient.contact.gender	The gender of a person used for administrative purposes.	Required	AdministrativeGender
Patient.maritalStatus	The domestic partnership status of a person.	Extensible	Marital Status Codes
Patient.contact.relationship	The nature of the relationship between a patient and a contact person for that patient.	Extensible	v2 Contact Role
Patient.animal.species	The species of an animal.	Example	AnimalSpecies
Patient.animal.breed	The breed of an animal.	Example	AnimalBreeds
Patient.animal.genderStatus	The state of the animal's reproductive organs.	Example	GenderStatus
Patient.communication.language	A human language.	Extensible, but limited to All Languages	Common Languages
Patient.link.type	The type of link between this patient resource and another patient resource.	Required	LinkType

8.1.2.2 Constraints

• pat-1: On Patient.contact: SHALL at least contain a contact's details or a reference to an organization (expression on Patient.contact: name.exists() or telecom.exists() or address.exists() or organization.exists())

Notes:

• multipleBirth can be either expressed as a Boolean (just indicating whether the patient is part of a multiple birth) or as an integer, indicating the actual birth order.
• Patient records may only be in one of two statuses: in use (active=true) and not in use (active=false). A normal record is active, i.e. it is in use. Active is set to 'false' when a record is created as a duplicate or in error. A record does not need to be linked to be inactivated.
• The link element is used to assert that two or more Patient resources are both about the same actual patient. See below for further discussion
• There should be only one preferred language (Language.preference = true) per mode of expression.
• The Contact for a Patient has an element organization, this is for use with guardians or business related contacts where just the organization is relevant.

8.1.3 Patient id's and Patient resource id's

A Patient record's Resource Id can never change. For this reason the identifiers with which humans are concerned (often called MRN - Medical Record Number, or UR - Unit Record) should not be used for the resource's id, since MRN's may change, i.e. as a result of having duplicate records of the same patient. Instead they should be represented in the Patient.identifier list where they can be managed. This is also useful for the case of institutions that have acquired multiple numbers because of mergers of patient record systems over time.

8.1.4 Linking Patients

The link element is used to assert that patient resources refer to the same patient. This element is used to support the following scenarios where multiple patient records exist:

8.1.4.1 Duplicate Patient records

Managing Patient registration is a well known difficult problem. Around 2% of registrations are in error, mostly duplicate records. Sometimes the duplicate record is caught fairly quickly and retired before much data is accumulated. In other cases, substantial amounts of data may accumulate. By using a link of type 'replaced-by', the record containing such a link is marked as a duplicate and the link points forward to a record that should be used instead. Note that the record pointed to may in its turn have been identified as created in error and forward to yet another Patient resource. Records that replace another record may use a link type of 'replaces' pointing to the old record.

8.1.4.2 Patient record in a Patient index

A Patient record may be present in a system that acts as a Patient Index: it maintains a (summary of) patient data and a list of one or more servers that it are known to hold a more comprehensive and/or authorative record of the same patient. The link type 'refer' is used denote such a link. Note that linked records may contain contradictory information. The record referred to does not point back to the referring record.

8.1.4.3 Distributed Patient record

In a distributed architecture, multiple systems keep separate patient records concerning the same patient. These records are not considered duplicates, but contain a distributed, potentially overlapping view of the patient's data. Each such record may have its own focus or maintaining organization and there need not be a sense of one record being more complete or more authorative than another. In such cases, links of type 'see also' can be used to point to other patient records. It is not a requirement that such links are bilateral.

8.1.5 Patient vs. Person vs. Patient.Link vs. Linkage

The Person resource on the surface appears to be very similar to the Patient resource, and the usage for it is very similar to using the Patient.Link capability.
The intention of the Person resource is to be able to link instances of resources together that are believed to be the same individual. This includes across resource types, such as RelatedPerson, Practitioner, Patient and even other Person resources.
The Patient Link however is only intended to be used for Patient resources.

The primary use case for the Person resource is to be able to support person registries that do not necessarily have a healthcare context, and are able to identify and quantify confidence levels that this is the same person.
This could include consumer portals where the maintainer of the person information is the actual person themselves.
A system could use the Person entry to cross check changes to information applied to one part of a record to values in another system; e.g., when moving, a consumer updates his contact numbers and address in his person record, and then a Patient Administration system is able to see that this data is changed and prompt the organization to follow up with the patient that was linked to the person record if they want their details updated, or if they no longer need services and they should be cancelled, as they've moved from the area.

The Linkage resource and the Patient.link property conceptually perform similar functions in FHIR, both provide an assertion of linkages between multiple resource instances that are referring to the same underlying individual.
When a Patient resource is linked/merged then it needs to have an internal indication that there is another patient resource that should be considered when referencing other records, which is achieved using the patient.link property.
Not detecting/checking for a potential linkage could mean that related clinical records are not discovered, potentially impacting patient safety. (which is why using the Linkage resource is not appropriate, as its use in this manner would force the use of either another query to potentially locate other patient resources to consider, or use _revInclude)

8.1.6 Patient.contact vs. RelatedPerson

The contact element on the Patient Resource should be used for storing people to contact information. Where a system has a separate record for other people for purposes other than just the contact details, the RelatedPerson resource should be used.
This includes cases where these related people are actually contributing to the record, and need to be referenced individually (e.g. CarePlan.Participant, Encounter, DocumentReference, Appointment) where the Patient.Contact component cannot be used.

It is not expected that these records will be used for recording the primary care provider; this information should be stored in the Patient.generalPractitioner field.

8.1.7 Patient Gender

Tracking a patient's gender presents a number of challenges due to biological variations, differing cultural expectations and legal restrictions, and the availability of various kinds of gender re-assignment. The basic gender included in Patient.gender has a limited use, that of the administrative gender: the gender that the patient is considered to have for administration and record keeping purposes. In addition, to this gender, other kinds of gender may be represented:

• Birth Sex - the sex assigned at birth / on the birth registration. Some countries allow variations such as not yet determined, unknown, or undifferentiated, while others do not. The US realm defines a US Specific extension for this for Meaningful Use
• Clinical Gender - an observation about the patient, typically using the LOINC code 76691-5 ). LOINC also provides a set of possible codes , or SNOMED CT has the descendents of 285116001 : Gender identity finding

Other related Observations may describe the Karyotypic/Genetic, Gonadal, Ductal, Phenotypic status of a patient.

For veterinary use the animal component also includes the genderStatus which indicates sterility information.

8.1.8 Mother and newborn relationships

There are several ways to represent the relationship between a mother and a child. This is due to the when it is recorded and the purpose for which it is recorded:

• To express the family relationship and legal responsibility thereof for administrative purposes: use the Patient/RelatedPerson structure.
  This structure is consistent over time.
• To relate the encounter of a mother and her baby for a maternity encounter, for administrative and billing purposes: use the encounter.partof property
• To collect information about the patient's relatives that might be relevant to the patient's medical condition: use the FamilyMemberHistory resource

During a maternity encounter, the Patient and Encounter resources for the mother will be present. After the child is born, new Patient, Encounter and RelatedPerson (for the mother) records will be created. The Child's encounter should reference the Mother's encounter using the partOf property.
The Patient/RelatedPerson structure should also be created for ongoing usage, as shown in this example:

<Patient>
	<id value="child"/>
	<!-- The details of the child -->
</Patient>
<RelatedPerson>
	<id value="rp-mom"/>
	<patient>
		<reference value="Patient/child"/>
	</patient>
</RelatedPerson>
<Patient>
	<id value="pat-mom"/>
	<!-- The details of the mom -->
	<link>
		<other value="rp-mom"/>
		<type value="see-also"/>
	</link>
</Patient>
<Encounter>
	<id value="mom-enc"/>
	<status value="in-progress"/>
	<class value="inpatient"/>
	<patient>
		<reference value="Patient/mom"/>
	</patient>
</Encounter>
<Encounter>
	<id value="child-enc"/>
	<status value="in-progress"/>
	<class value="inpatient"/>
	<patient>
		<reference value="Patient/child"/>
	</patient>
	<partOf>
		<reference value="Encounter/mom-enc"/>
	</partOf>
</Encounter>

8.1.9 Merging records

This specification does not specify merge functionality: if multiple patient records are found to be duplicates, they can be linked together, as described above. These links merely express the relationship between records, and in the case of a replacement link, indicate a "master" record. This specification does not mandate that FHIR servers migrate information between such records on finding such a link. Note:

• Health information administrators may call the process "merging", but it is often implemented as "linking" at the record level
• Servers are allowed to implement merging/record migration even though it is not mandated.

STU Note: We are seeking input from the implementer community on what effect linking/merging/unlinking should have on other functionality such as the GET operation (where the result is the old version of the Patient), searching, reverse includes, etc.; e.g., should observation resources from all linked/merged patients be returned when querying for one of them?
How should an unlink behavior be done? (Assuming that no data was "re-allocated" as part of merge) These suggested updated behaviors could be the subject of a future connectathon.

Feedback here .

8.1.10 Patient Matching using an MPI

A Master Patient Index (MPI ) is a service used to manage patient identification in a context where multiple patient databases exist. Healthcare applications and middleware use the MPI to match patients between the databases, and as new patient details are encountered. MPIs are highly specialized applications, often tailored extensively to the institution's particular mix of patients. MPIs can also be run on a regional and national basis.

To ask an MPI to match a patient, clients call the patient $match operation, which processes a parameters resource containing a complete or fragment of a patient resource, along with some other control parameters.
This provided patient resource does not need to pass full validation (mandatory fields, or invariants) as the resource will not be stored, it does however need to be a parsable instance.
The MPI can then use the properties of the resource as MPI inputs, and processed using an internal MPI algorithm of some kind to determine the most appropriate matches in the patient set. It does not have to use all the properties provided, and may ignore others provided quietly.
A specific profile (with the required fields/invariants) can be used to define what parameters the MPI algorithm requires.

  POST [base]/Patient/$match
  [some headers including content-type xml or json]
  [parameters body with patient resource inside]

The response from an "mpi" $match operation is a set of patient records, ordered from most likely to least likely. If there are not patient matches, the MPI SHALL return an empty search set with no error, but may include an operation outcome with further advice. All patient records SHALL have a score from 0 to 1, where 1 is the most certain match, along with an extension "match-grade" that indicates the MPI's position on the match quality:

  <entry> 
    <resource>
      <Patient>
        <!-- patient details -->
      </Patient>
    </resource>
    <search>
      <extension url="http://hl7.org/fhir/StructureDefinition/match-grade">
        <valueCode value="probable"/>
      </extension>
      <score value="0.80"/>
    </search>
  </entry> 

The match-grade extension has one of the following codes:

certain	This record meets the matching criteria to be automatically considered as a full match.
probable	This record is a close match, but not a certain match. Additional review (e.g. by a human) may be required before using this as a match.
possible	This record may be a matching one. Additional review (e.g. by a human) SHOULD be performed before using this as a match.
certainly-not	This record is known not to be a match. Note that usually non-matching records are not returned, but in some cases records previously or likely considered as a match may specifically be negated by the matching engine

The purpose of using an MPI search versus a regular search is that the MPI search is really intended to target and find a specific single patient for recording information about reducing errors through incorrectly selecting the wrong patient. Often MPIs won't return data if there is insuffience search parameter data, such as a partial surname.
This compares to a regular search which can be used for finding lists of patients, such as to locate a group of patients that share a property in common, such as live in a specific location, or fit within an age range for performing population analysis.

A formal definition for the MPI $match operation is published.

8.1.11 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	Expression	In Common
active	token	Whether the patient record is active	Patient.active
address	string	A server defined search that may match any of the string fields in the Address, including line, city, state, country, postalCode, and/or text	Patient.address	3 Resources
address-city	string	A city specified in an address	Patient.address.city	3 Resources
address-country	string	A country specified in an address	Patient.address.country	3 Resources
address-postalcode	string	A postalCode specified in an address	Patient.address.postalCode	3 Resources
address-state	string	A state specified in an address	Patient.address.state	3 Resources
address-use	token	A use code specified in an address	Patient.address.use	3 Resources
animal-breed	token	The breed for animal patients	Patient.animal.breed
animal-species	token	The species for animal patients	Patient.animal.species
birthdate	date	The patient's date of birth	Patient.birthDate	2 Resources
death-date	date	The date of death has been provided and satisfies this search value	Patient.deceased.as(DateTime)
deceased	token	This patient has been marked as deceased, or as a death date entered	Patient.deceased.exists()
email	token	A value in an email contact	Patient.telecom.where(system='email')	4 Resources
family	string	A portion of the family name of the patient	Patient.name.family	1 Resources
gender	token	Gender of the patient	Patient.gender	3 Resources
general-practitioner	reference	Patient's nominated general practitioner, not the organization that manages the record	Patient.generalPractitioner (Practitioner, Organization)
given	string	A portion of the given name of the patient	Patient.name.given	1 Resources
identifier	token	A patient identifier	Patient.identifier
language	token	Language code (irrespective of use value)	Patient.communication.language
link	reference	All patients linked to the given patient	Patient.link.other (Patient, RelatedPerson)
name	string	A server defined search that may match any of the string fields in the HumanName, including family, give, prefix, suffix, suffix, and/or text	Patient.name
organization	reference	The organization at which this person is a patient	Patient.managingOrganization (Organization)
phone	token	A value in a phone contact	Patient.telecom.where(system='phone')	4 Resources
phonetic	string	A portion of either family or given name using some kind of phonetic matching algorithm	Patient.name	3 Resources
telecom	token	The value in any kind of telecom details of the patient	Patient.telecom	4 Resources