Business Rules

Patient Summary Submissions

A patient summary submission must include a Bundle, a Composition with its referenced resources, and Composition Sections with their referenced resources. All referenced resources must have a .id value that is guaranteed to be unique within the submitted bundle (but does not have to be globally unique).

The composition must have a globally-unique lifetime identifier (UUID) in Composition.identifier. This value is populated by the submitting POS when the patient summary is first produced and submitted (Composition.status = "final"), and must be re-used for every subsequent update (Composition.status = "amended") and/or cancellation (Composition.status = "entered-in-error").

Composition Section Rules

The following Composition Sections are required on every patient summary. A section absent reason of "nilknown" must be provided if data is not available or not applicable for the subject patient:

  • Medications – when data is available, must include Medication Statement with its related Medication resource for each reported prescribed medication.
  • Allergies – when data is available, must include an AllergyIntolerance resource for each reported allergy or substance intolerance.
  • Problems – when data is available, must include a Condition resource for each reported medical condition or problem-list item.

The following Composition Sections are optional, to be populated when data is available and appropriate for the subject patient:

  • Procedure History – when data is available, the unstructured textual content is populated in the Note field, with one Note entry for each reported procedure.
  • Vital Signs – each patient summary is expected to include the most recent height and weight measurements for the patient.
    • Patient height must be included in an ObservationBodyHeight resource, and patient weight in an ObservationBodyWeight resource. At the discretion of the authoring healthcare provider, multiple (historical) observations can be included for either or both measurements as additional resource entries.
    • Body Mass Index (BMI) is recommended but not required. When data is available, an ObservationBMI resource is included for each reported measurement.
    • Head Circumference is recommended but is not required for infant patients. When data is available, an ObservationHeadCircumference resource is included for each reported measurement.
    • Social History – when lifestyle or risk factors are available, a SocialHistoryObservation resource is included for each reported lifestyle or risk factor.
  • Family Member History – when data is available, a FamilyMemberHistory resource is included for each reported medical procedure or condition for each reported family member.

Constraints (invariants) have been set on elements and references within various profiles in PS-AB to prevent the submission of confidential data that has not been specifically authorized for patient summary purposes, in accordance with the Health Information Act (HIA) of Alberta.

Resource Rules

Composition

  • Composition.meta.security is used to capture Alberta’s privacy and security settings. The following values are accepted:
    • "R" = restricted (privacy setting for confidential health information). Required on all PS submissions
    • "PRS" = patient’s requested sensitivity. Used when the authoring provider chooses to mask patient summary data in response to the patient’s expressed wish under the Health Information Act (HIA).
    • "PHY" = physician requested sensitivity. Used when the authoring provider has determined that the submitted PS must be masked, independently of a patient’s expressed wish.
  • Composition.author must be an individual healthcare provider who has authority under HIA to disclose the PS data to Alberta Health
  • Composition.attester is not accepted on PS-AB submissions
  • Composition.custodian.display is set by default to ‘Alberta Health’ as the party responsible for the data upon submission

Patient

  • Patient.identifier is required, and must be a unique person identifier assigned by a jurisdictional health authority. The Alberta ULI/PHN should be sent whenever available; otherwise an out-of-province healthcare number is accepted. Only one identifier should be included.
  • Patient.telecom of type Phone is the only communication type accepted, as the only telecommunication method currently allowed when confidential healthcare information is being sent to or received from a patient.
  • Patient.generalPractitioner is not included on PS-AB submissions, as this information will be obtained from the province’s Central Patient Attachment Registry.

Practitioner / Practitioner Role

  • Practitioner.identifier is required, and must be a unique provider identifier as issued for use in the Province of Alberta. Allowed provider identifier types include:
    • Practitioner ID (PRACID) issued by Alberta Health
    • CC Provider ID issued by Alberta Health Services
    • License ID issued by a regulated professional College in Alberta
    • Practitioner.name must include the authoring provider’s legal name (.use = "official"), and may additionally include a preferred name (.use = "usual").
    • Practitioner.role information is populated as applicable to the provider’s role in authoring the patient summary.

Location

  • Location data must represent the physical or virtual location where the patient summary data is managed and/or maintained by the authoring provider.
  • Location.identifier is required, and must be a recognized delivery site identifier as issued by Alberta Health.

Allergy / Intolerance

  • AllergyIntolerance.clinicalStatus cannot be inferred or derived from data in the patient’s chart. It is populated only when a corresponding status has been clearly and explicitly captured in the chart.
  • AllergyIntolerance.type is desired, when the submitting system has the equivalent categorization available in the patient’s chart.
  • No coding terminology has been established in Alberta for allergies / intolerances. The name or brief description of the reported allergy or intolerance must be sent in AllergyIntolerance.code.text.
  • AllergyIntolerance.onset[x] is required for each reported allergy or intolerance. It is populated with the estimated or actual date, age or timeframe when the allergy or intolerance was identified or began manifesting (either as clinically recorded or as self-reported by the patient).

Condition

  • Condition.clinicalStatus cannot be inferred or derived from data in the patient’s chart. It is populated only when a corresponding status has been clearly and explicitly captured in the chart.
  • Condition codes from a supported medical terminology are preferred, but not required. When available, conditions may be coded using ICD-9, ICD-10 or SNOMED CT CA.
  • When a code is not available, the condition or problem name must be sent in Condition.code.text.
  • Condition.onset is required. Partial dates are accepted if a full / exact date of onset is not known.

Family History

  • FamilyMemberHistory.relationship.text must contain a text description of the family member’s relationship to the patient for any reported entry. Shortened or abbreviated relationship types are to be avoided. Relationship names should be gender-specific (e.g. ‘grandmother’ rather than ‘grandparent’) when known.
  • FamilyMemberHistory.condition.onset[x] is highly desired, when available. It may be recorded as a full or partial date (actual or estimated), age (actual or approximate), or a text description of an age or life stage (e.g. ‘early childhood’, ‘pre-menopause’, ‘teenage’, etc.)

Medication Statement / Medication

  • MedicationStatement is included on PS-AB to capture relevant prescribed medication information. Medication dispenses are not included in a patient summary, as this data is submitted provincially through separate channels.
  • MedicationStatement.extension:RenderedDosageInstruction can be used to populate a text string of composite medication information, when discrete elements such as medication name, strength, dosage, etc. have not been charted; otherwise dosage details are populated in MedicationStatement.dosage, and medication data is populated in the referenced Medication resource.
  • Medication codes from a recognized Canadian drug terminology are preferred, but not required. When available, either DIN codes or CCDD codes are accepted.
  • When a code is not available, the medication name must be sent in Medication.code.text.

Observations

  • Observation.status is set to "final" for all reported vital signs.
  • Observation.code must be populated with the appropriate LOINC value for the type of measurement being reported (body height, body weight, BMI or infant head circumference).

Procedure

  • Alberta does not expect that patient charts will contain the detailed data that a true Procedure FHIR profile would require, when collecting information about historical procedures that have occurred throughout the patient’s lifetime. Therefore, procedure history is reported in the patient summary using the Procedure Section.Notes area of the Composition.
  • Relevant information from the patient’s chart is concatenated into a single text entry for each reported procedure.
  • Date or timeframe of the procedure should be populated at the start of any concatenated text string, when available.

Social History

  • Lifestyle and/or risk factors are reported for all relevant factors as determined by the authoring provider.
  • AB uses the generic Social History profile for all types of lifestyle factors, including tobacco and alcohol use. However, vendor systems that are already using the dedicated Tobacco Use and/or Alcohol Use profiles may choose to submit data in that format, in place of the generic SocialHistory profile. The generic Social History profile will be the only one included in vendor conformance for PS-AB for lifestyle risk factor data.
  • No coding terminology has been established in Alberta for lifestyle or risk factors. The name or brief description of the reported lifestyle or risk factor must be sent in SocialHistory.code.text.
  • Observation.value[x]:valueString is used to capture any relevant quantification or supplemental detail, as available.