Overview
Background
A patient summary is defined by ISO/TR 12773-1:2009 (Business Requirements for Health Summary Records) as a “health record extract comprising a standardized collection of clinical and contextual information (retrospective, concurrent, prospective) that provides a snapshot in time of a subject of care’s health information and healthcare.”
A patient summary is not expected to be an exhaustive or comprehensive record of all medical data for that patient. As such, the Alberta patient summary would not be used as the mechanism to transfer a patient’s complete medical record from one provider to another, or from one system to another. The patient summary is designed to provide an easily consumable synopsis of the most relevant information, to improve coordination of care across the care team and to inform clinical decision-making throughout the patient’s journey.
As a provincial EHR, Alberta Netcare is designed to collect and compile a broad range of clinical information from many diverse source systems and clinical authors. Alberta’s approach to the patient summary enables submission of this important clinical data from primary care physicians, and enables publication in Netcare where it is accessible to healthcare professionals across the entire patient journey.
Scope
Authoring providers will independently submit a patient summary to the provincial data integration hub for publication in Alberta Netcare. It is expected that authoring providers will have a longitudinal relationship with the patient to ensure that data remains current and accurate over time.
Alberta has designed its patient summary contents to include those sections where the authoring provider is appropriately deemed to be the most authoritative provincial source of that information; and excluding sections for information that is already being contributed to Alberta Netcare through other channels from the appropriate sources (such as lab or DI results from the testing facilities, or medication dispenses from the issuing pharmacies).
The following shows the scope of information included in the Alberta patient summary:
Author (submitting provider) - The author is a healthcare provider whose scope of practice covers the clinical content of the Patient Summary. The author is expected to have a continuing longitudinal relationship with the patient, so that consumers have confidence that the information will be kept current on an ongoing basis after initial submission.
Conditions (Problem List) - This section contains a compact list of all medical conditions or diagnosed problems that are relevant to patient care and clinical decision-making. Prior conditions that are not actively treated or manifested may be included when relevant.
Allergies - This section contains a list of allergies and adverse reactions to any agent, allergen or class of allergens; either diagnosed by the author, or reported by the patient and acknowledged or confirmed by the author.
Prescribed Medications - This section contains a list of current prescribed medications curated by the author.
Measured Observations - This section contains quantified healthcare observations as measured and recorded by the author (or author’s organization).
Procedure History - This section contains a list of past medical procedures. Detailed information is not always available for historical procedures that have been reported by the patient; therefore, this section is unstructured to accommodate any available data from the authoring provider.
Lifestyle / Risk Factors - This section lists any relevant lifestyle factors or healthcare risks, such as smoking or alcohol consumption.
Family History - This section contains a list of relevant medical conditions or procedures for biological relatives of the patient (e.g. parents, siblings, biological children).
Intended Audience
This guide is intended for business and technical implementers of the Alberta Patient Summary. Readers of the technical content should have an understanding of the fundamentals of HL7 FHIR R4.0.1 and the RESTful paradigm.
Contact
Connect with HISCA:
Email: hisca@gov.ab.ca