Ontario Patient Summary HL7© FHIR© Implementation Guide

Patient Summary Conceptual Data Model

This model is linked to Ontario’s Electronic Health Record (EHR) Conceptual Information Model 2.0 (CIM 2.0). See:

https://ehealthontario.on.ca/files/public/support/Architecture/Ontario_EHR_CIM_2.0.pdf

To support the use of structured data through the adoption of data content and health terminology standards in the solution, this CDM also includes high-level entity relationships and attributes discovered in versions of FHIR interoperability standard for patient summary specifications. The model does not repeat the structure of the messages laid out in FHIR. Links to FHIR specs are included for entity definitions and field code values. In any difference of meaning between cited FHIR elements and this model, FHIR is the authoritative voice. This model relies on the following specifications:

FHIR R4 - The current official version of FHIR as of the time this implementation guide was published.
International Patient Summary FHIR Implementation Guide - This specification is a key input into the design of the Ontario Patient Summary Implementation Guide.
Patient Summary - Canadian Edition Release 1 (PS-CA) - The Ontario Patient Summary is intended to be closely aligned to this Pan-Canadian Patient Summary initiative.

Conceptual Data Model ERDs and Metadata

Entity Relationship Diagrams (ERDs) follow. These include:

a conceptual high-level ERD for solution data structures for the Release 1 solution, including metadata for each entity,
an ERD for the Client & Provider subject area (including metadata for each entity) which is not called out as a FHIR Profile but is included because all other entities in the model are dependent on it,
six subject area ERDs, one for each of the six Release 1 Patient Summary profile subject areas; each Subject Area corresponds to a Profile defined for the FHIR International Patient Summary (see http://hl7.org/fhir/uv/ips/ipsStructure.html ), and metadata is included for each attribute, and
one non-clinical subject area ERD with metadata for each attribute, for Patient Summary document composition.

ERD Legend

Patient Summary Conceptual Data Model

PS-ON R1 ERD

Entity Name	Description	FHIR Resource Name
Client Supporter	Legal entity (i.e. either an individual or an organization) holding rights and responsibilities for a health care client with respect to health care. A health care client managing his or her own care acts as the health client. Where care of a health care client is legally managed by another person, that person is the health client. Includes power of attorney and substitute decision maker. Includes personal representative, advocate, healthcare proxy, legal representative, financially responsible entity. It includes information about contact method e.g. geographic or virtual address, telephone number.	Patient.Contact (Contact element within Patient Resource)
Drug	Any substance or mixture of substances used in the diagnosis, treatment, mitigation or prevention of a disease, disorder or abnormal physical state, or its symptoms, or when used for non-medical purposes, solely for its effects on the central nervous system. Includes prescription drugs, herbal medicine, vitamins, minerals, Chinese medicine, and other over the counter medicines. Also there are extemporaneous mixtures which are combinations of drugs. May have the following attributes: administration route drug identification e.g. DIN name, including brand name and generic name, in English and French manufacturer therapeutic class pharmaceutical format (e.g. capsule, tablet) strength (e.g. 200 mg.)	Medication / Medication Request
Health Care Provider	Describes a health care provider involved in the delivery of healthcare services. Encompasses both professional and non-professional members. Has professions, areas of practice for which the provider is qualified. May have information on clinician credentialing and privileging as defined by the applicable professional and governing organizations. This includes remote participation (e.g., via tele-health activities such as tele-consultation, home health monitoring.) Includes any information about licensing status and license suspension. May be an author, authenticator or scribe/transcriber of clinical documentation. Has a Unique Provider Identifier, a key assigned by eHealth to uniquely identify each Provider. May have a health system universal ID. May have a license number or national provider identifier (U.S.). May have multiple unique identifiers.	N/A
Health Care Provider Role	A part played by a health care provider (regulated or unregulated) that provides a type of care to a particular health care client. Examples: Acupuncturist Advanced Care Paramedic Audiologist Certified Graduate Nurse Chiropractic Clinical Counsellor Combined Lab and X-Ray Technologist Communicable Disease Case Investigator Counsellor Critical Care Paramedic Dental Assistant Dental Hygienist Dental Technician Dentist Denturist Emergency Medical Responder Homeopath Home Support Worker Kinesiologist Lab Technician Licensed Practical Nurse Marriage and Family Therapist Medical Doctor Medical Laboratory Technologist Medical Officer of Health Midwife Nuclear Medicine Technologist Occupational Therapist Optician Optometrist Paramedic Practitioner Pharmacist Pharmacy Technician Physiotherapist Personal Support Worker Podiatrist Primary Care Paramedic Psychiatrist Psychologist Psychotherapist Radiation Technologist in Magnetic Resonance Radiation Technologist in Radiation Radiation Technologist in Therapy Recreation Therapist Registered Acupuncturist Registered Clinical Social Worker Registered Dietitian Registered Massage Therapist Registered Midwife Registered Nurse Registered Nurse Practitioner Registered Psychiatric Nurse Respiratory Therapist Social Services Worker Social Worker Speech Language Pathologist Speech Therapist Veterinarian	Practitioner Role
Health Concern	An issue that prompts an encounter with a Health Care Provider, such as: a health symptom or complaint experienced by the health care client, e.g. headaches, back pain, or a health need expressed by the health care client, e.g., continuing good health, or a requirement by a third party to establish the health care client's health state, e.g. for life insurance, pilot licensing, job application or retention. May become a health care client Reason for Encounter. In the Patient Summary context, it is clinical problems or conditions that are currently being monitored for the patient. Used to provide a concise overview of active health conditions affecting the patient.	Procedure
Health Condition	A mode or state of being, the state of being fit: the physical status of the body as a whole or of one of its parts usually used to indicate abnormality. May include a descriptive narrative. Over time a health condition can change in nature or acuity, or split or merge. It includes all diseases and disorders, specifically to denote any illness, injury, disease, or complications from existing health conditions or treatment. A health condition may be contagious, having implications on health care client management. A health condition may be genetically based. A health condition can also be positive, e.g. pregnancy, wellness. It can be physical, mental or emotional. In the Patient Summary context, it is the historical information and events that the patient has previously encountered. To provide a comprehensive overview of a patient’s healthcare interactions that could improve clinical diagnosis, treatment, and condition management. Used to provide a comprehensive overview of a patient’s healthcare interactions that could improve clinical diagnosis, treatment, and condition management.	Condition
Healthcare Client	An individual participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. (U.S. National Library of Medicine - Medical Subject Headings) A natural person (i.e. a human being) who: is eligible to receive health care services in Ontario, or has received or is receiving health care services in the province of Ontario (i.e. a health care client). This entity covers personal identifying information but not health information. It includes information about: identity within the health system e.g. a Health Number; each care setting may have a separate unique ID. E.g. a research study may uniquely identify a health care client as a test subject. administrative gender, e.g. Male, Female, undisclosed adoption: whether or not the health care client was adopted birth and death dates official versus preferred name whether or not the health care client would prefer to receive correspondence The health care client's identity may be unknown e.g. for a protected person or if the identity of the health care client is unknown. A health care client may be a VIP whose identity must be omitted from reporting. A health care client may be identified by an alias. Health care client-identifying information could include a photograph. May be elated genetically or by physical co-location (e.g. residential, occupational, travel, etc.) to another person not necessarily a health care client. Depending on care setting, a health care client may be referred to as: Patient (currently receiving care) Participant (in a clinical study) Resident (of a long term care facility) Subject (in a public health case) Client (in home care/community care cases/ settings)	Patient
Intervention	Activity performed for a health care client with the intention of directly or indirectly improving or maintaining physical or psychological condition. May include: provider treatment self-care preparatory activity e.g. fasting requirements, pre-medication clinical test activities i.e. diagnostic interventions and assessments. transfer activity, i.e. movement of the health care client from one care setting to another. information about deviation from research trial protocol. that an activity was not attempted or not completed, including reasons e.g. information about overriding a drug interaction warning, including the reason for the override. reasons disease management or preventative services/wellness prompts from clinical care guidelines were overridden. intervention, but less invasive procedures such as physiotherapy, massage, or blood donation also apply. Includes intake of a substance, ingestion and implantation i.e. of medical devices. A psychotherapy session would be an example of altering a psychological condition. May be one in a sequence of treatments. May be completed, attempted, not attempted, or not completed. May be performed by a health care provider or the health care client. Also may include: treatment name date and time of treatment site administering provider reactions and complications details associated with continuous treatments (e.g., infusions, tube feedings, bladder irrigations, suction levels) routine scheduling, "one-time", "on-call" or "PRN" reason treatment not given and/or related activity not performed. In the Patient Summary context, it is a description of past procedures that are pertinent for patient care.	Procedure
Patient Summary Document	An immutable set of resources with a fixed presentation that is authored and/or attested by humans, organizations, and devices.	Bundle (Patient Summary Document Container)
Provider Organization	An organization that provides health care or other health-related services or products. Includes e.g. insurers and transcription services. May have information on service classification e.g. Regional Cancer Centre. (For Single Sign on application, a Provider Organization may be a Sponsoring Organization, a Health Care organization that has users that require access to at least one Federated Service. 2015-6-15)	Organization
Provider Person	Describes a health care provider involved in the delivery of healthcare services. Encompasses both professional and non-professional members. Has professions, areas of practice for which the provider is qualified. May have information on clinician credentialing and privileging as defined by the applicable professional and governing organizations. This includes remote participation (e.g., via tele-health activities such as tele-consultation, home health monitoring.) Includes any information about licensing status and license suspension. May be an author, authenticator or scribe/transcriber of clinical documentation. Has a Unique Provider Identifier, a key assigned by eHealth to uniquely identify each Provider. May have a health system universal ID. May have a license number or national provider identifier (U.S.). May have multiple unique identifiers.	Practitioner
Sensitivity	A susceptibility to an agent or substance or category of substances, such that exposure to it is likely to result in a harmful physiological response rather than the expected (non-harmful, normal) physiological response AND where it has not been possible to determine whether the sensitivity is of the allergic type or not. (CHI) Includes the reason for the capture, update or removal of this information. Includes the source of the sensitivity information. Notations indicating whether item is patient reported, and/or provider verified may be maintained. In the Patient Summary context, it is all known allergies, intolerances, and/or reactions a patient has for medications or substances through any of the senses. Used to inform the treatment and care provisioning of an attending healthcare provider to identify problem or adverse events arising from action taken.	AllergyIntolerance
Substance Intake - Immunization	The administration of a substance into the body key to the management of a health care client's condition(s). May be self-administered or administered by a Health Care Provider. May be administered by a device. Intake can be medication or nutrition, e.g. daily consumption of food items, beverages, or oral medication, injected medication such as a pain killer or the topical application of a patch. It can be a meal type (e.g. breakfast), and can have a specific time or date associated with it. It can be PRN i.e. taken as needed, including adjustment of dosage to suit needs. An example of an intake is an immunization: an application of a technique (e.g. vaccination), that induces immune resistance to a specific disease by exposing the individual to an antigen in order to raise the level of antibodies to that antigen. May record: the immunization name/type, sequence number in the series & series identifier, strength and dose the date and time of administration manufacturer, lot number, expiration date route and site of administration administering provider observations, reactions and complications reason immunization not given, and/or immunization related activity not performed (e.g., due to a contraindication or a health care client's refusal), and identity of immunization-withholding provider. if the immunization is recorded or occasioned by a population-based schedule from a relevant public health immunization authority May include: drug name strength and dose site and route date, time and frequency of administration observations, reactions and complications reason medication not given (e.g. delay, refused, unavailable) medication related activity not performed. annotation, e.g., describing the dose to be administered based upon specific clinical indicators such as a sliding scale insulin order where the dose is based on the health care client's current blood sugar level. In the Patient Summary vaccine context, it includes vaccines, medications, and treatments associated with making a patient immune or resistant to certain complications or diseases. Used to provide a comprehensive overview of a patient’s healthcare interactions that could improve clinical diagnosis, treatment, and condition management.	Immunization
Substance Intake	The administration of a substance into the body key to the management of a health care client's condition(s). May be self-administered or administered by a Health Care Provider. May be administered by a device. Intake can be medication or nutrition, e.g. daily consumption of food items, beverages, or oral medication, injected medication such as a pain killer or the topical application of a patch. It can be a meal type (e.g. breakfast), and can have a specific time or date associated with it. It can be PRN i.e. taken as needed, including adjustment of dosage to suit needs. An example of an intake is an immunization: an application of a technique (e.g. vaccination), that induces immune resistance to a specific disease by exposing the individual to an antigen in order to raise the level of antibodies to that antigen. May record: the immunization name/type, sequence number in the series & series identifier, strength and dose the date and time of administration manufacturer, lot number, expiration date route and site of administration administering provider observations, reactions and complications reason immunization not given, and/or immunization related activity not performed (e.g., due to a contraindication or a health care client's refusal), and identity of immunization-withholding provider. if the immunization is recorded or occasioned by a population-based schedule from a relevant public health immunization authority May include: drug name strength and dose site and route date, time and frequency of administration observations, reactions and complications reason medication not given (e.g. delay, refused, unavailable) medication related activity not performed. annotation, e.g., describing the dose to be administered based upon specific clinical indicators such as a sliding scale insulin order where the dose is based on the health care client's current blood sugar level. In the Patient Context, it is a consolidation of medications that have been prescribed and dispensed to patient. Used to understand the range of medications the patient currently is taking or should be taking to treat their health condition or manage their wellness.	MedicationStatement