IPS

This project leverages the ongoing effort from the IPS project which has an established content and data model informed by FprEN 17269:2019 from CEN/TC 251 which uses both the HL7® CDA and HL7® FHIR® standards.

However, the PS-CA Use Cases and the implementation ecosystem are not identical to IPS. For example, the PS-CA specification has to account for jurisdictional differences in the following: system capabilities, established charting practices, and change management capacity. Notably, the PS-CA also has to account for creation of Canadian patient summaries through provider-generated summaries (as a result of an encounter to provide a snapshot of the patient's health care), as well as machine-generated summaries (created automatically by provincial electronic health records).

As a result, the PS-CA has applied a slightly different approach in implementing the data model from the original IPS project. While the elements within the IPS data model remain the same, the expectations for when and how the elements are implemented require a more nuanced approach.

The Pan-Canadian Patient Summary project leverages an iterative, consensus-driven, version-based approach for publishing specification content. For more information on the development process and roadmap, implementers are encouraged to review PS-CA Specification Preface.

Alignment with the International Patient Summary Global Specification (IPS-UV) As one of the early national adopters of IPS using FHIR, PS-CA (and its jurisdictional implementation - PS-ON) have worked extensively with the International Patient Summary FHIR working group to ensure the newest release of the IPS-UV specification adequately reflects expectations that are consistent and feasible for early implementers. See Profiling Conventions and Approach.

Part of this effort involved working with IPS-UV to provide more clarity in their mustSupport definitions as well as working with IPS-UV to be more regimented in where MS flags were applied. Over thirty Must Support flags were removed from IPS-UV as part of the efforts to refine it based on implementer feedback.

With these changes, only a handful of elements remain that are marked as Must Support in the IPS-UV that could not be marked as Must Support in PS-CA v1.0.0 TI. These elements are described in the section below and will be considered for tightening of constraints in PS-CA v2.0.0.

Differences between the IPS-UV and PS-CA Differences between the IPS-UV and PS-CA are largely limited to areas where further localization was required as well as a handful of areas where the PS-CA needed to relax system conformance expectations in the first version to align to "current state" jurisdictional capabilities.

Differences between this IPS-UV August 2022 CI Build profiles and the PS-CA profiles are noted on the respective profiles pages and summarized below.

Must Support Differences Elements that IPS-UV considers Must Support that are not Must Support in PS-CA v1.1.0 TI:

CodeableConcept.coding (change expected in IPS), Patient.telecom, Patient.address, Patient.gender, Patient.generalPractitioner, AllergyIntolerance.type, AllergyIntolerance.reaction.severity, Condition.clinicalStatus (No longer MS in IPS CI Build), Condition.category, Condition.severity, Medication.ingredient (backbone), Medication.ingredient.strength, MedicationStatement.dosage.timing, MedicationRequest.dosageInstruction.timing, Observation.valueCodeableConcept Terminology Approach Differences IPS is currently evolving its approach to modeling desired terminology that has been identified by the international specification. This change has resulted in the addition of the additionalBinding extension and the removal of terminology slices of the next release of IPS to allow implementers more flexibility in defining the terminology that is most appropriate in the given context of the implementation.

Domain Prioritization Differences Jurisdictional prioritization of certain domains over others in the initial trial implementation is also a driver of differences between the two specifications.

Given the aggressive timelines of the first phase of the Patient Summary project, and input from detailed consultation with participating jurisdictions, a national FHIR profile set that covers a subset of data domains was recommended for PS-CA version 1.0.0. PS-CA profiles were developed for this subset with the intent of developing the remaining PS-CA profiles in a later release.

This staggered approach has had a significant impact on how constraints are applied to the sections of the PS-CA Composition resource. Notably, IPS-UV applies Must Support flags to all its sections, whereas the PS-CA has only applied Must Support flags to the header section and recommended sections (Medication Summary, Allergies & Intolerances, Problem List, Immunization, History of Procedures) noted in the diagram below.

In order to maintain compliance with the IPS-UV, the PS-CA Composition has maintained the required cardinality on Medication Summary, Allergies & Intolerances, and Problem List sections. However, it provides clear guidance to implementers for what should be included within the section.entry element if:

for a given patient, no information exists for that section, or the implementing system can not produce the section (due to lack of capability, jurisdictional restrictions, etc.). Domain/Profile Additions Additionally, to support the emerging needs of jurisdictions to pilot Patient Summary sections that do not have an IPS-UV profile developed for them yet, this guide has developed two new profiles that it will propose to IPS-UV following successful pilots.

The two profiles below were developed to meet the needs of an initial piloting jurisdiction and while they are informed by the modeling of similar international and Canadian profiles, they have not gone through the same number of public review cycles as the other profiles in this specification. For this reason, the status on these profiles is still considered Draft.

Observation Social History (PS-CA): A higher level parent profile meant to house a broader set of social history observations, and to house coded and non-coded lifestyle risk factors (e.g., alcohol use details, amount of exercise, etc.) Family Member History (PS-CA): A profile intended convey details and notes regarding the relevant family member conditions that recorded for a patient.

CA-Baseline

The PS-CA specification attempts to profile in a way that allows the patient summaries (instances) to be conformant to the Canadian Baseline specification without having to formally derive from the profiles in the specification.

In places where profiling of the PS-CA uncovers challenges with the CA Baseline (e.g., CA Baseline requiring an element as Must Support that is not in the PS-CA or IPS-UV) these challenges are noted but should be resolved at the CA Baseline-level according to the established due diligence review criteria.

Alignment with the Canadian Baseline The FHIR Profiles defined in the PS-CA Implementation Guide, are aligned to the FHIR Canadian Baseline Profiles, version 1.0.2.

The FHIR Canadian Baseline profiles have been developed to help improve interoperability among healthcare IT solutions across Canada. This standard makes use of the CA Baseline in the following ways:

informally aligns to the constraints of the CA Baseline profiles claims a dependency on CA Baseline Implementation Guide to make use of its artefacts (e.g., extensions, value sets, etc), declares conformance to the CA Baseline through the validation of examples against the CA Baseline constraints To learn more about the Baseline and its benefits, or to contribute to advancing the maturity of the FHIR Canadian Baseline Profiles, please visit Canada Health Infoway’s FHIR Implementers Working Group here.

Use of CA Baseline Profiles Currently, there are a handful of CA Baseline profiles that are directly used. These include the references to Practitioner, PractitionerRole, and Organization in the Composition profile.

The references to the CA Baseline profiles will remain until/unless additional requirements identify a need to apply constraints that go beyond what is defined in the CA Baseline profiles. In your Ig you can render the tree the same as you see on Simplifier with the diff/hybrid/snapshot buttons.

Jurisdictional-Context

Alignment to Work Underway with Jurisdictions Some jurisdictions may already be working on their own jurisdictional content. Both PS-CA and jurisdictional content should be informed by the same high-level principles from the Pan-Canadian Coordinating Table.

Jurisdictional content is expected to be meet the minimum expectations outlined in the PS-CA specification, this ensures that all implementors across the country are building from same foundational data model (leading to economies of scale with vendors). With this approach, customizations and differences across jurisdictions are minimized to only implementation specific details (e.g., tighter cardinality on elements that support specific integration requirements from jurisdictional health assets).

In the cases where jurisdictions have begun profiling work, the PS-CA specification development team has worked collaboratively with the jurisdiction to compare the specifications, align where appropriate, and identify any areas that need to be relaxed in the national profile, or resolved further through the international specification. Jurisdictional content developed after the initial draft of the PS-CA is published is expected to align to the minimum expectations outlined in the PS-CA specification and ideally directly derive from the profiles in the PS-CA FHIR® package.

Differences between the PS-CA and Jurisdictional Content Jurisdictional content will never break the expectations of this specification, meaning it is never expected to have looser constraints than those put forth the PS-CA. Rather any additional constraints put forth through jurisdictional content are expected to be the result of tightening of the expectations outlined in PS-CA (e.g., applying a Must Support flag to an element that is noted for tightening in future releases but is currently lacking support from a number of participating jurisdictions at the pan-Canadian level).

Additionally, some jurisdictions may also apply constraints on elements specifically needed for integration with their existing digital health assets (e.g., additional provider identity requirements to leverage an existing digital health asset integration).

Understanding the scope of the jurisdictional content also plays a critical role in understanding the differences between the two types of content. Additional expectations outlined in the jurisdictional content that has been developed to date solely reflect the expectations for systems generating, storing, and transmitting summaries produced within that jurisdiction. These additional expectations have not been scoped to apply to summaries received from other jurisdictions, and therefore should not be interpreted as such.

Additional guidance will be provided on interpreting jurisdictional constraints as jurisdictions move to support intra-jurisdictional and international exchange of patient summaries in later releases.

Jurisdictional Patient Summary Content Jurisdictional details may be hosted in a jurisdictional guide or project space. In cases where a jurisdiction is starting to surface implementation details through derived profiles - those derived profiles can be found in their project space and have been rendered below (through packaging) for reader convenience.

Implementers are encouraged to review the additional constraints, localizations, and implementation details published by jurisdictions.

Ontario Implementation Details The Ontario Patient Summary is based on the International Patient Summary standard and was developed in collaboration with Canada Health Infoway and other jurisdictions and with preliminary input from primary care clinicians and solution vendors.

The Ontario Patient Summary (PS-ON) Standard aligns, where applicable, to the International Patient Summary (IPS) HL7 FHIR standard, the Pan-Canadian Patient Summary (PS-CA) Standard (under concurrent development), and the Canadian Baseline (CA-Baseline).

Notably, the PS-ON Standard is scoped for patient summaries generated, stored, and transmitted within Ontario. This is in contrast to the PS-CA Standard, which is intended to support intra-jurisdictional use, cross-jurisdictional use, and cross-border use. This difference in scope is the root of most of the variances between PS-CA and PS-ON.

Implementers are encouraged to review the Ontario Patient Summary FHIR Implementation Guide to learn more about the relationship between the specifications and to review details regarding Patient Summary implementation in Ontario.

Ontario Patient Summary FHIR Implementation Guide

Alberta Implementation Details Alberta is in the process of developing implementation details to provide to their implementers.

At the time of the September 2022 release, details lke usage notes, comments, mappings, and additional constraints have been applied within PS-AB profiles that are derived from the PS-CA profiles.

Implementers are encouraged to review the Alberta Patient Summary space to read about the additional constraints, localizations, and implementation details published by jurisdictions.

Alberta Patient Summary Project Space

This guide will continue to be updated as additional jurisdictions adopt the content present in this guide.

Specification Guidance