Business Rules

Patient Identification

Patient identifier (Patient.identifier) is required to uniquely identify a patient. Alberta Personal Health Number (PHN) should be provided when available. The patient's health care number from another jurisdiction if the patient is from outside the province and does not have a ULI may also be used.

Practitioner Identification

Practitioner identifier (Practitioner.identifier) is required to uniquely identify a provider. The provider’s billing identifier (Practitioner ID) as issued by Alberta Health is the preferred identifier when available. Otherwise, license number or registration number issued by the regulatory college shall be provided as part of the Practitioner resource when that resource is present. Additionally, Connect Care Practitioner ID may also be provided.

Location Identification

Location identifier (Location.identifier) is required to uniquely identify a location, as registered with Alberta Health for healthcare service delivery. Where available, the AH Billing ID for the healthcare delivery site is included. Otherwise, a site-level WDFA ID is used.

Bundle Identification

Bundle ID (Bundle.id) is required and is assigned by receiver upon successful validation of submitted patient summary instance. A new UUID is assigned per instance of a patient summary. Note: CII will make location (using Bundle.id) resolvable

Bundle identifier (Bundle.identifier) is required and is assigned by the submitter (e.g. submitting EMR). It must be the same for every updated instance of patient summary. Additionally, it must be globally unique, and it must match the Composition.identifier (see below).

Composition Identification

Composition identifier (Composition.identifier) is required and is assigned by submitter (e.g. submitting EMR). It must remain the same for the same patient, author and patient summary instance. It could be a UUID, but if not a UUID, then the identifier.value + identifier.system – the Alberta Health assigned naming system (URI) – must be globally unique.

Note: Composition.identifier is used as Accession ID in Alberta Netcare.

Note: Composition ID (Composition.id) is not used.

Author

The Author is the health care provider who curates the patient summary before it is submitted. The provider remains the author even for automatic updates.

Custodian

The Custodian element of a patient summary in the context of Alberta is the party responsible for the ongoing maintenance of and access to patient summary, which is Alberta Health.

Creating a Patient Summary

A patient summary is created by a health care provider for their patient using relevant information in the provider’s point of service system. Therefore, a patient might have multiple active Patient Summaries created by different providers based on information from different point of service systems. All data included in a patient summary must pertain to the patient identified in the patient summary as the subject. When a patient summary is initially submitted, the Composition.status must be set to “final”. The following are guidelines for compiling relevant clinical data for inclusion in a patient summary.

Note: FHIR resource attributes with cardinality set to 0..0 must have no value sent (i.e. it must be omitted) in a patient summary submission.

Patient Summary Section	Scope	Out of Scope	Notes
Prescribed Medications	This section contains a list of current medications prescribed by the author.	Vaccines are excluded from this section and are out of scope.	Medication name must be provided. Optionally, if available, DIN could also be provided. If patient does not have prescribed medications (i.e. Medications section is empty), section emptyReason must be set to “nilknown”.
Allergies and Intolerances	This section contains a list of allergies, intolerances 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.		As there is limited codification and standardization of allergy/intolerance, a free-text description of allergy and/or intolerance is accepted. Submitters are encouraged to provide optional coded allergies and/or intolerance in addition to free text when available. If patient does not have allergies and/or intolerances (i.e. Allergies section is empty), section emptyReason must be set to “nilknown”.
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.		As there is limited codification and standardization of condition, a free-text description is accepted. Submitters are encouraged to provide optional coded conditions in addition to free text when available.
History of Procedures	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.		If patient has history of procedure, the narrative must be entered in section text and section emptyReason must be set to “narrative-only”.
Vital Signs	This section contains quantified healthcare observations as measured and recorded by the author (or author’s organization) (e.g., height, weight, etc.).		Height and weight are mandatory while BMI is optional. Head circumference is applicable only for infants.
Social History	This section lists any relevant lifestyle factors or healthcare risks known to the author, such as smoking or alcohol consumption.		If patient does not have lifestyle factors or healthcare risks (i.e. Social History section is empty), section emptyReason must be set to “nilknown”.
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).		As there is limited codification and standardization of family member history, a free text description is accepted. Submitters are encouraged to provide optional coded family history in addition to free text when available. If patient does not have family history (i.e. Family History section is empty), section emptyReason must be set to “nilknown”.

Replacing a Patient Summary

A provider is required to keep a patient’s patient summary up-to-date and will therefore submit several versions of patient summary over time. When a health care provider makes changes affecting the content of the patient summary in their point of service system, the provider should submit a new version of patient summary with Composition.status set to “amended”. When a patient summary is replaced, the previous patient summary will no longer be accessible in Alberta Netcare. Note: The “current version” of a patient summary is defined as the most recent version submitted from the authoring provider’s point of service system

Cancelling a Patient Summary

If a patient summary has been submitted for a wrong patient, the Author must re-send with Composition.status set to “entered-in-error”. Note: When cancelling a patient summary, the emptyReason for all sections must be set to “unavailable”.

Data and Information Exclusion

Data and information that patient has indicated to be excluded from patient summary must be honoured and not sent in patient summary submission.