Business Context Index > Business Rules
Business Rules
Patient Identification
Patient identifier is required to uniquely identify a patient. Ontario health card number should be provided when available. The HIC may also provide the patient's medical record number, Ontario Health Enterprice Client ID (ECID), or the health care number from another jurisdiction if the patient is from outside the province. Implementers shall contact Ontario Health to obtain the system URL for the medical record number.
Practitioner Identification
Practitioner identifier is required to uniquely identify a practitioner. The practitioner’s license number or registration number issued by the regulatory college shall be provided as part of the Practitioner resource when that resource is present.
Organization Identification
Organization identifier is required to uniquely identify an organization. The organization's identifier shall be the Provincial Provider Registry Unique Provider Identifier (UPI) and will be provided by Ontario Health at the time of implementation.
Creating a Patient Summary
A Patient Summary is created by a health care practitioner for their patient using relevant information in the practitioner’s point of service system. Therefore, a patient might have multiple active Patient Summaries created by different practitioners 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.
The following are guidelines for compiling relevant clinical data for inclusion in a Patient Summary based on Canada Health Infoway Draft Patient Summary Minimum Data Set v0.50.
| Patient Summary Section | Scope | Out of Scope | Notes |
|---|---|---|---|
| Medication Summary | Prescription medications, non-prescription, over-the-counter medications, and any complementary or alternative medicines. | Vaccines are excluded from this section and are managed by the Immunizations section. | If no information about medications is available, a reason of “No medication info” must be specified. If a patient is known to have no medications, “No known medications” must be specified. |
| Allergies and Intolerances Synonym: Allergies and Adverse Reactions |
Current and any relevant historical allergies, intolerances, and adverse reactions to all substances including prescription and non-prescription medications, food, and other substances. | If no information about allergies and intolerances is available, a reason of “No allergy info” must be specified. If a patient is known to have no medications, “No known allergies" must be specified. | |
| Problem List | Current problems that have not been resolved or are existing concerns that are still being monitored. | Resolved or past problems are excluded from this section and are managed by the Past History of Illness section where applicable. | If no information about medications is available, a reason of “No problem info” must be specified. If a patient is known to have no problems, “No known problems" must be specified. |
| Immunizations | Vaccination names, types, and dates, including due dates for repeats, administration method and practitioner details | ||
| History of Procedures Synonym: Surgical History |
Invasive diagnostic procedures, therapeutic procedures, and surgical procedures. Generally, from the past six months but may include procedures and interventions from over past six months that are relevant. | When the PoS system contains text only for a procedure and cannot distinguish Procedure from Condition based on code, it is acceptable to include the procedure under the Past History of Illness section rather than under History of Procedures | |
| Past History of Illness Synonym: Medical History; Problems Resolved |
Relevant diagnoses, problems, and treatments or therapies a patient has undergone, and relevant medical | Allergies or intolerances are managed by the Allergies or Intolerances section. |
Replacing a Patient Summary
A HIC is required to keep a patient’s Patient Summary up-to-date and will therefore submit several versions of the patient’s Summary over time.
When a health care practitioner from a given HIC makes changes affecting the content of the Patient Summary in their point of service system, the practitioner should submit a new version of Patient Summary, using the same business identifier as the original submission.
- The “current version” of a Patient Summary is defined as the most recent version the HIC submitted from its point of service system which has not been archived (logically deleted) per Ontario Health retention policy.
- A “historical version” of a Patient Summary is any version that pre-dates the current version and has not been archived per Ontario Health retention policy.
Invalidating a Patient Summary
When a health care practitioner from a given HIC organization reviews a patient summary that they have authored, they may choose to mark it as invalid to indicate that it was entered in error or is otherwise inaccurate. Invalidated patient summaries are still viewable by consumers but must have a clear visual indicator in the consuming application to distinguish valid from invalid documents.
If the previously submitted patient summary has been invalidated by a clinician from the HIC organization, the entire series of the patient summaries (using the same Bundle identifier) will no longer be valid for use in the EHR, and the PoS system must create a new identifier for future submission of the corrected patient summary and its subsequent updates.
Masked Data
If a patient record is masked in the source PoS system it should not be included in the patient summary submission. PS-ON does not implement security tags at this time.
Author and Attester
The Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. By virtue of signing off the Patient Summary, the Author would also be the Attester, i.e. the individual who attests to the accuracy of the Patient Summary composition. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would be the PoS System and the Attester would be the HIC.
Custodian
The Custodian element of a patient summary identifies the "Health Information Custodian" (as that term is defined in PHIPA) that provides the Patient Summary to Ontario Health as a Prescribed Organization for the purposes of the EHR.